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V 


THE 


PRmCIPLES  AND  PRACTICE 

OP 

DENTAL    SURGERY, 


BY 

CHAPIN  A.  HARRIS,  M.D.,  D.D.S.; 

LATE   PRESIDENT   OF   THE   BALTIMORE   COLLEGE   OF     DENTAL   SORQERT  ;     MEMBER   OF   THE   AMERICAN 

MEDICAL    ASSOCIATION  ;     AUTHOR   OF    DICTIONARY   OF    MEDICAL   TERMINOLOaY    AND 

DENTAL  SURGERY,  ETC.,  ETC.,  ETC. 


THREE  HUNDRED  AND  TWENTY  ILLUSTRATIONS. 


PHILADELPHIA  : 
LINDSAY   &   BLAKISTON 

18G3. 


Entered  according  to  Act  of  Congress,  in  the  year  1863,  by 

LINDSAY    &    BLAKISTON, 

in  the  Clerk's  Office  of  the  District  Court  of  th-e  United  States  for  the  Eastern 
District  of  Pennsylvania. 


Henry  B.  Asiimfad,  Printi-.r, 

Xo».  1102  nnd  1104  Sansom  St. 


IaJU 
100 


Neik^fi^i  t$  tie  cfeaJiJi] 


THOMAS    E.    BOND,    M.  D., 

PROFESSOR   OF    SPECIAL  PATHOLOGY    AND   THERAPEUTICS   IN   THE    BALTIMORE   COLLEGE    OF 
DENTAL    SURGERY, 

AS    A    TOKEN    OF    GRATITUDE    FOR    MUCH    KINDNESS,    AND    AS    A 

TESTIMONY    OF    RESPECT   AND    ESTEEM   FOR    GREAT 

PROFESSIONAL  AND  PRIVATE  WORTH, 

THIS     VOIjXJ]VtE 

IS  RESPECTFULLY  DEDICATED, 

BY    HIS    FEIBND, 

AND    OBEDIENT    SERVANT, 


THE    AUTHOR. 


PUBLISHERS'  PREFACE 

TO    THE    EIGHTH   EDITION. 


The  Publishers,  in  preparing  this,  the  first  posthumous 
edition  of  the  late  President  Harris'  Principles  and'  Prac- 
tice of  Dental  Surgery,  have  spared  no  pains  to  make  it 
in  every  way  worthy  of  its  own  high  reputation  and  that 
of  its  distinguished  Author. 

It  has  been  subjected  to  a  very  thorough  revision  by 
competent  professional  gentlemen,  and  will  be  found  to 
contain  many  and  important  additions,  bringing  the  work 
fully  up  to  the  present  state  of  Dental  Science  and  Art. 

The  Pubhshers  desire  to  acknowledge  the  valuable 
assistance  rendered  by  Professor  Austen,  to  whom  they 
are  indebted  for  the  entire  chapter  on  Vulcanite,  most  of 
the  chapter  on  Soldering,  and  much  new  matter,  in  the 
chapter  on  Irregularity,  and  throughout  the  entire  Mechani- 
cal Division  of  the  work.  They  would  also  acknowledge 
important  additions  by  Prof.  Christopher  Johnston,  of 
the  Baltimore  College;  a  valuable  section  on  artificial 
Palates  by  Dr.  Wm.  H.  Dwinelle,  and  a  number  of  useful 
practical  suggestions  from  Dr.  Edward  Maynard. 

The  illustration  of  the  work  has  been  greatly  improved. 
A  few  unimportant  designs  have  been  omitted ;  several 
others   have   been  replaced   by  improved   drawings  and 


vi  publishers'  preface  to  the  eighth  edition. 

many  new  illustrations  have  been  added,  for  a  large  num- 
ber of  which  they  are  indebted  to  the  courtesy  of  Dr. 
Samuel  S.  White. 

The  Publishers  lay  this  edition  before  the  Profession  in 
the  confident  assurance  that  it  will  be  found  to  be  what 
its  Author  designed  it, — a  thorough  elementary  treatise, 
a  text-book  for  the  student,  and  a  useful  companion  and 
guide  for  the  practitioner. 

PlllLADELrUIA,  Sept.  1,  1863. 


PREFACE 

TO    THE    SEVENTH   EDITION 


In  revising  his  Principles  and  Practice  of  Dental  Sur- 
gery for  a  Seventh  Edition,  the  author  trusts  that  no 
abatement  of  effort  will  be  discovered  on  his  part  to  render  it 
every  way  worthy  of  a  continuance  of  the  approbation  it  has 
hitherto  received.  Nearly  every  page  has  been  carefully 
revised',  and  additions  have  been  introduced  throughout 
the  entire  work.  Three  new  chapters  and  a  number  of 
new  illustrations  have  also  been  added.  In  short,  he  be- 
lieves that  no  valuable  improvement  or  discovery,  coming 
within  the  scope  of  this  work,  has  been  omitted  in  the 
present  edition. 

CHAPIN  A.  HARRIS. 

No.  51  North  Charles  St.. 
Baltimore,  Sept.  1858. 


PREFACE 

TO    THE   SECOND    EDITION. 


In  submitting  to  the  profession  a  Second  Edition  of  his 
Dental  Practice,  the  author  is  happy  to  avail  himself  of 
the  opportunity  to  express  his  grateful  appreciation  of 
the  approbation  which  the  First  has  received.  He  trusts 
that  the  additions  which  he  has  made  to  the  primary  work 
will  make  the  one  now  presented  still  more  acceptable. 
The  alteration  in  the  plan,  which  has  resulted  from  the 
effort  at  improvement,  has,  however,  rendered  a  slight 
change  of  title  necessary,  in  order  to  express  the  character 
of  the  present  book. 

In  the  First  Edition,  the  Anatomy  of  the  Mouth  was 
omitted,  because  a  thorough  knowledge  of  it  can  be  ob- 
tained from  works  on  General  Anatomy.  But  it  has  been 
suggested  that  such  works  may  not  be  at  hand  when  wanted 
by  the  dental  student,  and  the  author  has  thought  it  better 
to  furnish  a  description  of  the  several  structures  which 
enter  into  the  formation  of  this  cavity.  He  has,  however, 
confined  himself  to  brief  expositions  of  the  parts;  not 
wishing  to  encumber  the  work,  or  distract  the  student 
with  the  consideration  of  matters  foreign  to  the  purpose 
for  which  it  was  written,  and  for  which  he  trusts,  it  will 
be  read.     He  is  indebted  to  Bourgery's  Anatomy,  Quain 


PREFACE    TO    THE    SECOND    EDITION.  IX 

and  Wilson's  Anatomical  Plates,  Wilson's  Anatomy,  and 
Smith  and  Horner's  Anatomical  Atlas,  for  a  number  of  the 
illustrations  used  in  this  part  of  the  work. 

The  Second  and  Fifth  Parts  embody  the  substance  of  two 
papers,  by  the  author,  which  were  written  subsequently 
to  the  publication  of  the  first  edition.  The  subjects  of 
them  came  properly  within  the  plan  of  the  present  work. 

The  object  of  the  author  in  the  preparation  of  this 
edition  has  been  to  provide  a  thorough  elementary  trea- 
tise on  Dental  Medicine  and  Surgery,  which  might  be  a 
text  book  for  the  student  and  a  guide  to  the  more  inex- 
perienced practitioner;  and  he  hopes  that  the  modifications 
he  has  introduced,  and  the  additions  he  has  made,  will  en- 
title it  to  be  so  considered,  at  least,  until  an  abler  hand 
shall  prepare  a  better. 


CONTENTS. 


PART    FIRST 


Anatomy  and  Physiology  of  the  Mouth, .27 

Preliminary  Remarks,        ........  27 

CHAPTER  FIRST. 

Organs  of  Prehension,.         .........  28 

Origin  and  Insertion  of  these  Muscles  or  their  Attachments,  29 

1.  Levator  Labii  Superioris  Alfeque  Nasi,       ....  29 

2.  Levator  Anguli  Oris, 29 

3.  Depressor  Labii  Inferioris,          ......  29 

4.  Depressor  Anguli  Oris,  .......  29 

5.  Zygomaticus  Major,  .         .         .         .         •         .         .         .29 

6.  Zygomaticus  Minor,         .         .         .         .         .         .         .  29 

'7.  Buccinator, 30 

8.  Orbicularis  Oris,     ........  30 

9.  Depressor  Labii  Superioris,          ......  30 

10.  Levator  Labii  Inferioris,          ......  30 

CHAPTER  SECOND. 

Organs  of  Mastication, 31 

Passive  Organs  of  Mastication,     ......  31 

The  Superior  Maxillary  Bones,  ....                   •         .  31 

Inferior  Maxillary  Bone,          .......  35 

The  Palate  Bones, 3S 

The  Teeth, ■      .         .         .  39 

The  Temporary  Teeth, 40 

The  Permanent  Teeth,    .......  41 

The  Pulp, 41 

The  Dentine,           ........  45 

The  Enamel,      ....                   61 

The  Cementum, 54 


xii  CONTENTS. 

PAGE. 

Description  of  Teeth  belonging  to  each  Class, 56 

The  Incisors, ..........  56 

The  Cuspidati,  or  Cuspids,          .                  .....  57 

The  Bicuspids, 58 

The  Jlolars, 60 

Articulation  of  the  Teeth, 61 

Diti'erenccs  between  the  Temporary  and  Permanent  Teeth,         .         .  62 

Relations  of  the  Teeth  of  the  Upper  to  those  of  the  Lower  Jaw,  .  62 


Active  Organs  of  Mastication, 
The  Temporal  Muscle,    . 
The  Masseter  Muscle, 
Pterygoideus  Externus, 
Pterygoideus  Internus, 


64 
64 
65 
65 
66 


CHAPTER  THIRD. 

OUGANS    OF    I.NSALIVATION,            .........  67 

The  Parotid  Gland, 67 

The  Submaxillary  Glands 68 

The  Sublingual  Glands, 69 

The  Mucous  Glands, 69 

CHAPTER  FOURTH. 

Organs  op  Deglutition,         .........  70 

The  Pharynx, 70 

Muscles  of  the  Pharynx,    .  .         .         .         .         .71 

The  Soft  Palate, ■         .  72 

Muscles  of  the  Soft  Palate, 73 

The  Tongue, 74 

Papillae  of  the  Tongue,     .......  75 

Muscles  of  the  Tongue,           ......  75 

The  Mucous  Membrane  Lining  the  Mouth,         ....  77 

The  Gums, 79 

The  Alveolo-dental  Periosteum,         ......  79 

CHAPTER  FIFTH. 

Blood-vessels  of  the  Mouth, 81 

Arteries  Supplying  the  Organs  of  Prehension,        ...  82 

Arteries  Supplying  the  Organs  of  Mastication,           ...  83 

Arteries  Supplying  the  Organs  of  Insalivation,      ...  84 

Arteries  Supplying  the  Organs  of  Deglutition,           ...  84 

Synopsis  of  the  Branches  of  the  External  Carotid  Artery,  •  .  86 

The  Veins, 86 

CHAPTER  SIXTH. 

The  Nehves  of  the  Mouth, 87 

Trigcmini,  or  Fifth  Pair  of  Cranial  Nerves,  .....  87 

Ophthalmic  Branch,          , 88 

The  Superior  Maxillary  Branch, 89 

Inferior  Maxillary  Branch,        .         .         .         .         .         .         .  '       .  91 

The  Facial  Nerve,  or  Portio  Dura  of  the  Eighth  Pair,  ...  93 

Anatomical  Relations  of  the  Mouth, 95 

Physiological  Relations, 96 


CONTENTS.  xill 

PAGE. 

CHAPTER  SEVENTH. 

Origin  and  Formation  of  the  Teeth,  .         ...         .         .98 

Formation  of  the  Dentine,     .         .         .         .         .         .         .  108 

Formation  of  the  Enamel,         .         .         .         .         .  .         .113 

Formation  of  the  Cementum,  or  Crusta  Petrosa,  .         .         .         .  116 

CHAPTER  EIGHTH. 

First  Dentition,    .         .         .         .         .         .         .         .         .         .         .117 

Eruption  of  the  Temporary  Teeth,         .         .         .         .         .         .  IIT 

Morbid  Eifects  resulting  from  First  Dentition,  .         ....  121 

CHAPTER  NINTH. 

Shedding  of  the  Temporary  Teeth,         ......  125 

CHAPTER  TENTH. 

Second  Dentition.           ..........  130 

Accretion  of  the  Jaws,          ........  133 

CHAPTER  ELEVENTH. 

Method  of  Directing  Second  Dentition, 138 

CHAPTER  TWELFTH. 

Irregularity  of  the  Teeth,      ........  144 

Treatment,        ...........  146 

Application  of  Vulcanite,      .         .         .          .         .         .         .         .  16(i 

CHAPTER  THIRTEENTH. 

Excessive  Development  of  the  Lower  Teeth  and  Alveoli,        .         .163 

Treatment,    ...........  163 

CHAPTER  FOURTEENTH. 

Protrusion  of  the  Lower  Jaw, 166 

Treatment, 166 

CHAPTER  FIFTEENTH. 

Peculiarities  in  the  Formation  and  Growth  of  the  Teeth,    .         .  168 

CHAPTER  SIXTEENTH. 

Osseous  Union  of  the  Teeth,  ........  172 

CHAPTER  SEVENTEENTH. 

Supernumerary  Teeth, 174 

CHAPTER  EIGHTEENTH. 

Third  Dentition,         .         .         • 176 


XIV  CONTENTS. 


PART    SECOND. 

> Physical  Characteristics  of  the  Tketh,  Gums,  Lips,  and   Tongue: 

OF  Salivary  Calculus  and  the  Fluids  of  the  Mouth,    .        .     183 

CHAPTER  FIRST. 
General  Considerations,   .........         185 

CHAPTER  SECOND. 

Physical  Characteristics  of  the  Teeth, 196 

Class  first 196 

Class  second,     ..........  198 

Class  third, 199 

Class  fourth, 201 

Class  fifth, 201 

CHAPTER  THIRD. 
Physical  Characteristics  of  the  Gu.ms,      ......     205 

CHAPTER  FOURTH. 
Physical  Characteristics  of  Salivary  Calculus,   ....        215 

CHAPTER  FIFTH. 
Physical  Characteristics  op  the  Fluids  of  the  Mouth,   .        .        .     220 

CHAPTER  SIXTH. 
Physical  Characteristics  of  the  Lips,    ......        223 

CHAPTER  SEVENTH. 
Physical  Characteristics  of  the  Tongue, 226 


PART    THIRD. 

Diseases  of  the  Teeth — Dislocation  of  the  Lower  Jaw,      .  231 

Diseases  op  the  Teeth,         . 233 

CHAPTER  FIRST. 

Gabies  of  the  Teeth, 234 

Differences  in  the  Liability  of  Different  Teeth  to  Decay,  .         .         .  237 

Causes  of  Caries,  . 242 

Prevention  of  Caries,        .........  251 

Treatment  of  Caries,     .........  252 

CHAPTER  SECOND. 

Filing  Teeth, 254 

CHAPTER  THIRD. 

Filling  Teeth, 264 

Materials  Employed  for  Filling  Teeth, 266 

Gold  Foil, 266 


CONTENTS. 


XV 


Sponge  or  Crystaline  Gold, 

Silver,  Platina  and  Aluminium, 

Tin  Foil, 

Lead,         ....... 

D'Arcet's  and  Dr.  Wood's  Fusible  Alloys, 

Amalgam,  ...... 

Gum  Mastic,  ..... 

Gutta  Percha,  ..... 

Instruments  for  Forming  the  Cavity,     . 
Manner  of  Forming  the  Cavity, 
Instruments  for  Introducing  Gold  Foil,         .... 
Manner  of  Introducing,  Consolidating  and  Finishing  the  Filling, 

CHAPTER  FOURTH. 

Filling  Individual  Cavities  in  Tekth,        ..... 
Filling  the  Superior  Incisors  and  Cuspids,        .... 
Filling  the  Superior  Molars  and  Bicuspids, 
Filling  the  Inferior  Incisors  and  Cuspids,  .... 

Filling  the  Inferior  Molars  and  Bicuspids,     .... 

CHAPTER  FIFTH. 
Filling  Teeth  when  the  Lining  Membrane  is  Exposed, 


PAGE. 

268 
269 
269 

269 
270 
270 
271 
271 
272 
277 
281 


287 
296 
.302 
304 


310 


CHAPTER  SIXTH. 
Filling  Pulp  Cavities  and  Roots  of  Teeth. 


318 


CHAPTER  SEVENTH. 

Filling  Teeth  with  Crystaline  or  Sponge  Gold, 
Instruments  Employed  in  the  Operation, 
Introducing  and  Consolidating  the  Gold, 

CHAPTER  EIGHTH. 

Building  on  the  Whole  or  Part  of  the  Crown  of  a  Tooth, 


331 
331 
335 


338 


CHAPTER  NINTH. 


Tooth-Ache, 

Causes,    . 
Treatment, 


CHAPTER  TENTH. 


Extraction  of  Teeth, 

Indications  for  the  Extraction  of  Teeth, 
Instruments  Employed  in  the  Operation, 
Key  Instrument,  ..... 

Manner  of  Using  the  Key  Instrument, 
Forceps,        ...... 

Manner  of  Using  the  Forceps,  . 
Manner  of  Extracting  Roots  of  Teeth, 
Extraction  of  the  Temporary  Teeth, 
Hemorrhage  after  Extraction, 


345 
345 
350 


300 
357 
359 
359 
3(Jl 
363 
370 
373 
378 
378 


Xvi  CONTENTS. 

PAGE. 

CHAPTER  ELEVENTH. 

The  Use  of  Anesthetic  Agents  in  the  Extraction  of  Teeth,  381 

CHAPTER  TWELFTH. 

Atrophy  of  the  Teeth,               .         .         .         •        '•                  .         .  387 

Causes,             ...........  392 

Treatment. 395 

CHAPTER  THIRTEENTH. 

Necrosis  of  the  Teeth,          .........  396 

Causes, 397 

Treatment, 397 

CHAPTER  FOURTEENTH. 

Exostosis  of  the  Root.s  of  the  Teeth, 398 

Causes, 400 

Treatment, 401 

CHAPTER  FIFTEENTH. 

Spina  Ventosa  of  the  Tekth,     ........  402 

Causes,              403 

Treatment, 403 

CHAPTER  SIXTEENTH. 

Denvding  of  the  Teeth.                  404 

Causes,          ...........  405 

Treatment,                ..........  407 

CHAPTER  SEVENTEENTH. 

Spontaneous  Abrasion  of  the  Cutting  Edges  of  the  Front  Teeth,  408 

Causes, 409 

Treatment.        .........  410 

CHAPTER  EIGHTEENTH. 

.Mechanical  Abrasion  of  THE  Teeth, 411 

CHAPTER  NINETEENTH. 

Fractires  and  other  Injlries  to  the  Teeth  from  Mechanical  Violence,  413 

CHAPTER  TWENTIETH. 

Diseases  of  the  Dental  Pilp  and  Periosteum, 417 

Irritation,     ..........  418 

Inflammation,           ..........  424 

Sjiontaneous  Disorganization,        . 433 

Fungous  Growth 435 

(.•ssification,           ........          .          .  436 

InHainmation  of  the  Dental  Periosteum, 437 

CHAP  I'ER  TWENTY-FIRST. 

Dislocation  of  the  Lower  Jaw,          .......  439 


CONTENTS.  xvii 


PART    FOURTH. 


PAfiF.. 


Salivary  Calctlus — Diseases  of  the  Gums  and  Alveolar  Phocksses,  .  443 

CHAPTER  FIRST. 

Salivary  Calculus,       ..........  445 

Chemical  Constituents  of  Salivary  Calculus,         ....  44G 

Origin  and  Deposition  of  Salivary  Calculus,     .....  447 

Its  Effects  upon  the  Teeth,  Gums  and  Alveolar  Processes,     .         .  451 

Manner  of  Removing  Salivary  Calculus,  ......  453 

CHAPTER  SECOND. 

DlSE.\SES    OP    THE    GUMS,  .........  455 

Acute  Inflammation  of  the  Gums,         ......  457   ^ 

Chronic  Inflammation  and  Tumefaction  of  the  Gums,      .         .         .  457 

Causes, 4G0 

Treatment, .  462 

Mouth-washes,      ..........  464    ^ 

Morbid  Growth  of  the  Gums,  ........  466 

Causes,         ...........  467 

Treatment,        ...........  468 

Mercurial  Inflammation  of  the  Gums,   ......  469 

Treatment, 470 

Ulceration  of  the  Gums  of  Children,  with  Exfoliation  of  tlie  Alveoli,  471 

Causes, 47li 

Treatment, 473 

Adhesion  of  the  Gums  to  the  Cheeks,      ......  474 

CHAPTER  THIRD. 

Tumors  and  Excrescences  op  the  Gums  and  Alveolar  Processes,    .  475 

Causes, 475 

Treatment, 477 

CHAPTER  FOURTH. 

Alveolar  Abscess, 482 

Causes, 484 

Treatment,        ...........  484 

CHAPTER  FIFTH. 

Necrosis  and  Exfoliation  of  the  Alveolar  Processes,  .         .  489 

Causes, 402 

Treatment, 492 

CHAPTER  SIXTH. 

Gradual  Destruction  of  the  Alveolar  Processes,   ....  49.'5 

Causes,  ...  494 

Treatment, 495 

2 


XVlll 


CONTENTS. 


CHAPTER  SEVENTH. 

DlSPLACEMKXT  OF  THK  TeKTII   HY  OSSF.Ol'S  DkI'OSIT  IN  TIIKIR  SOCKETS, 

Causes,         ....•■••■• 
Troiitiiicnt, 


.     49G 

490 

.     497 


PART    FIFTH. 

Diseases  of  the  Maxillary  Sinis,  and  tiieiu  Treatment, 
CHAPTER  FIRST. 


PiiELiMiNAUY  Remarks, 


CHAPTER  SECOND. 


Inflammation  of  the  Lining  Membrane  of  the  Maxillary  Sinus,  . 
Symptoms,  .......... 

Causes,    ........... 

Treatment,  .......... 


499 


.501 


508 
509 
510 
511 


CHAPTER  THIRD. 

Purulent  Secretion  and  Encorc.ement  of  the  ^Iaxillary  Sinus, 
Symptoms,  .......... 

Causes,     .......... 

Treatment,    .......... 

Case  1st,  . 

Case  2d, 

Case  3d, 

Case  4th,       ......... 

Case  oil],  .         .         .         .         .         .         . 

Case  Ctl),       ......... 

Case  Ttli, 

Case  8th, 

Case  9th, 

Case  lotli, 


512 
51G 
517 
518 
523 
524 
525 
525 
52G 
527 
529 
531 
532 
532 


CHAPTER  FOURTH. 


AiiscESS  of  the  JIaxillary  Sinus,  . 
Symptoms,  .... 
Causes,   ..... 
Treatment,  .... 
Case  11  til. 


.533 
535 
53G 
537 
538 


CONTEXTS.  XIX 


PAOE. 

CHAPTER  FIFTH. 


Ulceration  ok  the  Lining  Membuane  op  the  Maxillary  Sinus,          .  542 

Symptoms,   ...........  542 

Causes,     ............  544 

Treatment,    ...........  545 

Case  12th, 547 

CHAPTER  SIXTH. 

Caries,  Necrosi.s  and  Softening  of  the  Walls  of  tue  Maxillary  Sini"S,  550 

Symptoms,  •         . .551 

Causes, 552 

Treatment,        .  .         .         .         .         .         .         .         .         .553 

Case  13th, 554 

Case  14th, 555 

CHAPTER  SEVENTH. 

Tumors  of  the  Membrane  and  Perio.steum  of  the  Maxillary  Sinus,  557 

Symptoms,        ...........  5(;0 

Causes,          ...........  5G1 

Treatment,        .         .         .  .         .  .         .  .         .501 

Case  15th, 564 

Case  IGth. 565 

Case  17th, 5G6 

Case  18th, 5G8 

Case  19th, 5(J9 

CHAPTER  EIGHTH. 

Exostosis  of  the  Osseous  Parietes  of  the  Maxillary  Sinus,   .         .  574 

Symptoms,    ...........  577 

Causes,     ............  577 

Treatment, 578 

Case  21st, 579 

Case  22d, 581 

CHAPTER  NINTH. 

Wounds  op  the  Osseous  Parietes  of  the  Maxillary  Sinus,     .         .  583 

Treatment,    ...........  584 

Case  23(1, 584 

CHAPTER  TENTH. 

Foreign  Bodies  in  the  Maxillary  Sinus,          .....  587 


CONTENTS. 


PAOB. 

PART    SIXTH. 

Mechanical  Pkntistry, >^>89 

Mcchiiiiical  Deulisjry,  .         . •''^'1 

CHAI'THll  FIRST. 

AUTIFR-IAI,    TkKTII, ■''•*'- 

CHAPTER  SECOND. 

SuusTANCES  Employed  as  Dental  Suhstitutrs,          ....  506 

Human  Tcetli, r)OG 

Teeth  of  Cattle, '>'^)^ 

Ivory  of  the  Elephant  and  Hippopotamus, 598 

Porcelain,  or  Incorruptible  Teeth, 599 

CHAPTER  THIRD. 

DiFFEUENT  Methods  ok  Inseiiting  Artificial  Teeth,  ....  GOT 

Artificial  Teeth  Placed  on  Natural  Roots, GOl 

Artificial  Teeth  Secured  by  Clasps, G03 

Artificial  Teeth  with  Spiral  Springs, G04 

Teeth  Retained  by  Atmospheric  Pressure,         .....  G03 

CHAPTER  FOURTH. 

PUK.I'AKATOUY    TuEAT.ME.NT    OF    THE    MoUTH,   ......  G09 

CHAPTER  FIFTH. 

PltEl'AK.VTlON    FOI!,   AND    MaXXER    OF    IXSEKTING    PiVOT    TeETH,               .             .  012 

CHAPTER  SIXTH. 

MaXNER  OF  IvEFrMXC,  Al.LOYIXG,  AND  ESTIMATING  THE  FiXENES.S  OF  GoLD,  G24 

.Manner  of  Refining  (iold, G'JG 

Alloying  Cold, G;V2 

Rules  and  Tables  for  the  Valuation  of  Cold, G.HS 

CHAPTER  SEVENTH. 

Manxek  of  Making  Gold  into  Plate  Spuings  and  Solder,     .         .  G37 

Gold  Solder, 041 

CHAPTER  EIGHTH. 

Cups  axd  .Materials  for  Impressions  of  the  Mouth — Plaster  Models.  04.3 

Impressions  in  Wax  and  Gutta-Percha, G4r> 

Plaster  Impressions,          .........  G48 

Plaster  .Models, 651 


CONTENTS. 


XXI 


CHAPTER  NINTH, 

Metallic  Dies  an'd  Counter-dies — Swaging  Plates, 
ywaging  Pliites,    ....... 

Fitting  the  Clasps, 


65G 
tJGl 
CG5 


CHAPTER  TENTH. 

PUINCIPLES    AND    APPLIANCES    OF    SOLDERINO,  .  .  .  .  .  670 

Soldering  Lamps,     .         .         .  .         .         .         .         .  .         .  G71 

Mouth  Blowpipes,         .........  C7 2 

Self-acting  Blowpipes,     .........  G7;J 

Bellows  Blowpipes,       .........  G74 

Hydrostatic  Blowpipes,    .........  G78 

Gas  Blowpipes,     ..........  G79 

Soldering  Pan,         ..........  G80 


CHAPTER  ELEVENTH. 

Antagonizing  on  Articulating  Models,   . 


G8:: 


CHAPTER  TWELFTH. 

Adjustment  op  Porcelain  Teeth  to  the  Plate — Finishing  Process,     .     687 
Finishing  Process,         .........         G95 


CHAPTER   THIRTEENTH. 

Artificial  Teeth  retained  by  Spiral   Springs, 
Artificial  Gum-Teetli,  Single  or  in  Sections, 


Gd'J 
702 


CHAPTER  FOURTEENTH. 

Artificial  Teeth  retained  by  Clasps, 

Position  and  Shape  of  Teeth  most  suitable  for  Clasps, 
Prevention  of  injury  resulting  from  use  of  Clasps, 
Central  Incisor  Avith  one  Clasp,  .         .         .         . 

Central  Incisor  with  two  Clasps,       .... 

Two  Central  Incisors  with  Clasps,         .         .         .         , 
Incisors  and  Cuspids  with  Clasps,    .... 

Bicuspids  with  one  Clasp,    ...... 

Bicuspids  and  First  Molars,  with  Clasps, 
Incisors,  Cuspids  and  Bicuspids  with  Clasps, 
Clasp-plate  where  only  one  Molar  remains, 
Lateral  Incisors,  and  Left  Bicuspids  with  Clasps, 


7or> 

705 
708 
700 
71(1 
710 
711 
712 
713 
711 
714 
71.-) 


CHAPTER  FIFTEENTH. 

Artificial  Teeth  Retained  by  Atmospheric  Pressure, 
The  Vacuum  Cavity,    ...... 


717 

724 


XX  ii  CONTENTS. 

PAdB. 

CHAPTER  SIXTEENTH. 

roricELAiN  Block  Tketii. '^30 

Silicious  anil  Aluminoiis  Materials,        ......  7^0 

Coloring  Materials,  .         .         .  •  '         •         •         .73  2 

Composition  and  Preparation  of  Bod}-, 73G 

Composition  and  Preparation  of  Tooth  Enamel,         ....  737 

Composition  and  Preparation  of  Gum  Enamel,      ....  739 

Antagonizing  Model  for  an  Upper  Set  of  Block  Teeth,      .         .         .  741 

Matrix  for  Moulding  the  Body,  Preparatory  to  Carving  the  Teeth,  742 

Moulding  and  Carving,    .........  744 

Crucing,  or  Biscuiting,           ........  746 

Enameling,      ...........  747 

Firing  and  Baking,       .........  747 

Fitting  and  Attaching  the  Blocks  to  the  Phitc,         ....  749 

CHAPTER  SEVENTEENTH. 

TeKTM    .set    IPOX    Pr,.VTIXA,    WITH    A    CONTINUOUS    AllTIFICIAL    Gu.M,         .  753 

CHAPTER  EIGHTEENTH. 
Ai'fi-iCATioN  OF  Vulcanized  India-Rubbei:  to  Dentistry,    .  .701 

■     CHAPTER  NINETEENTH. 

CuEoi'LASTic  Process,         .........  783 


PART    SEVENTH. 


Diseases  and  Defects  of  the  Palatine  Organs,        ....     797 
Preliminary  Remarks, 790 

CHAPTER  FIRST. 

Diseases  of  the  Palate, 800 

Tumors  of  the  Palate, 800 

Causes,    .         .  .  .  .         .  .         .802 

Treatment, 804 

Caries,  Necrosis  and  Ulceration  of  the  Palate,  ....     BOC 

Causes  and  Treatment,  ........  808 

Iiithimmation  and  Ulceration  of  ti'.e  Velum  and  Uvula,    .         .         .811 
Causes  and  Treatiuent.  .......  813 


CONTENTS.  XXIU 

PACF. 

CHAPTER  SECOND. 

Defects  of  the  Palatine  Ouoans,        .         .         .         .         .  .815 

Accidental  Defects,        .........         81.") 

Congenital  Defects,  .         .  .         .         .  .         .         .         .810 

Functional  Disturbances  caused  by  Defects  of  the   Palatine  Organs,     818 

CHAPTER  THIRD. 

Manner  of  Remedyino  Defects  of  the  Palatine  Organs,  .         .  822 

Staphyloraphj', 822 

Artificial  Obturators  and  Palates,      .......  832 

An  Artificial  Palate,  with  a  Velum  and  Uvula,      ....  8^6 

Mr.  Stearns'  Method, 837 

Dr.  HuUihen's  Method, 840 

Dr.  Kingsley's  Jlethod,       ........  843 

Combination  with  Artificial  Teeth, 853 


PART    FIRST. 


ANATOMY  AND  PHYSIOLOGY  OF  THE  MOUTH. 


FIRST  AND  SECOND  DENTITION. 


IRREGULAIIITY    OF    THE    TEETH. 


N      DEFORMITY   AND    PROTRUSION   OF    THE 
LOWER   JAW. 


PECULIARITIES    IN     THE     FORMATION    AND 
GROWTH  OF  THE  TEETH. 


OSSEOUS  UNION  OF  THE  TEETH. 


THIRD  DENTITION. 


PART   FIRST. 

ANATOMY  AND  PHYSIOLOGY  OF  THE  MOUTH. 


The  Mouth,  cavum  oris,  .signifies  in  the  human  subject,  the 
space  included  between  the  palatine  arch  above,  the  mylo-hyoid 
muscles  beneath,  the  lips  in  front,  the  velum  palati  behind,  and 
the  cheeks  on  either  side.  The  teeth  and  closed  jaws  separate 
the  inner  portion,  or  lingual  cavity,  from  the  outer,  or  vestibular 
space  ;  and  while  that  part  of  the  latter  bounded  by  the  cheeks 
ought  properly  to  bear  the  appellation  buccal,  the  term  buccal 
cavity  is  not  unfrequently  employed  with  a  signification  so 
general  as  to  comprehend  the  whole  oral  cavity. 

In  the  mouth  are  the  tongue,  teeth,  and  the  alveolar  ridges 
invested  by  the  gums :  into  it  are  poured  the  secretion  of  the 
parotid,  sub-maxillary  and  sub-lingual  glands,  as  well  as  that  of 
the  ordinary  mucous  and  of  the  special  lingual  follicles ;  and  in 
it  the  food  is  subjected  to  the  processes  of  mastication  and  in- 
salivation  previous  to  deglutition. 

It  is  farther  concerned  in  the  prehension  of  aliment ;  and  be- 
sides containing  the  organs  of  taste,  is  employed  in  articulation, 
expectoration,  suction,  kc. 

The  parts  concurring  to  constitute  the  mouth,  form  a  very 
complicated  piece  of  mechanism ;  through  them  it  has  a  wide 
range  of  sympathies,  and  by  them  performs  a  great  variety  of 
functions. 

The  anatomical  elements  composing  these  parts,  consist  of 
Bone,  Ligament,  Muscle,  Gland,  Blood-vessel,  Nerve,  Areolar 
and  Adipose  tissues  and  Mucous  membrane. 

These  difierent  elements  combine  together  and  form  the 
various  organs  which  constitute  the  mouth. 


28 


ORGANS   OF   PREHENSION. 


These  organs  I  shall  consider  in  their  physiological  order ; 
thus  combining  their  anatonn'  and  physiology,  studying  at 
the  same  time  both  their  healthy  structure  and  function — a  plan 
practically  taught  by  the  late  Professor  W.  R.  Handy,  in  the 
Baltimore  College  of  Dental  Surgery,  and  which  commends  it- 
self as  at  once  the  most  natural,  interesting  and  instructive. 


CHAPTER     FIRST 
ORGANS  OF  PREHENSION. 


-^m 


Fio.  1.   A  fniut  vii'W 


les  of  the 


face:  a  a  Anterior  bellies  of  uiciiiitu-fronta- 


lis  :  6  6  Orbicularis  palpebrarum;  ePyrami-  i 

dalis  nasi;  rf  Compressor  nasi;  eeand//    mOUtU. 


This  class  of  organs  may  be  said 
to  commence  the  digestive  process, 
and  it  comprises  those  which  seize 
the  food,  and  introduce  and  partly 
retain  it  in  the  mouth. 

They  consist  of  the  Elevators, 
Depressors,  and  Sphincter  mus- 
cles of  the  mouth,  which  are  as 
follows  : 

1.  Levator  labii  superioris  alse- 
que  nasi. 

2.  Levator  anguli  oris. 

These  two  muscles  elevate  the 
upper   lip  and  the  angle   of  the 


Levator  labii  superioris  ala>que  nasi ;  g  g 
Zygomaticus  miuor;  hh  Zygouiaticus  ma- 
jor ;  i  I  Masseter  muscle  \jj  Buccinator,  or 
trumpeter's  muecle  ;  k  k  Orbicularis  oris; 
/  /  Depressor  labii  inferioris ;  m  Levator 
mentl ;  n  n  Depressor  anguli  oris ;  o  o  Leva- 
tor anguli  oris. 


3.  Depressor   labii  inferioris — 
or  quadratus  menti. 

4.  Depressor    anguli   oris — or 
triangularis  oris. 

These  two  muscles  antagonize  the  first  and  depress  the  lower 
lip  and  angles  of  the  mouth. 

5.  Zygomaticus    major. 

6.  Zygomaticus  minor. 

7.  Buccinator. 

These  e-\tend  from  the  angles  of  the  mouth  to  the  prominence 


ORGANS    OF    PREHENSION.  29 

of  the  cheek.     Their  use  is  to  draw  the  angles  of  the  mouth  up- 
wards and  outward  towards  the  ear. 

8.  Orbicularis  oris. 

This  is  the  sphincter  muscle  which  surrounds  and  closes  the 
mouth. 

9.  Depressor  labii  superioris. 

10.  Levator  labii  inferioris. 

The  first  depresses  the  upper  lip  against  the  teeth — the  other 
raises  the  lower  lip. 


ORIGIN    AND    INSERTION  OF  THESE    MUSCLES,   OR    THEIR 
ATTACHMENTS. 

1.  Levator  Labii  Superioris  Alceque  Nasi,  arises  by  two  heads : 
first  from  the  nasal  process  of  the  superior  maxillary  bone ; 
second,  from  the  edge  of  the  orbit  above  the  infra-orbital  fora- 
men. It  is  inserted  into  the  ala  nasi  or  wing  of  the  nose  and 
upper  lip. 

2.  Levator  Anguli  Oris^  arises  from  the  canine  fossa  of  the 
superior  maxillary  bone,  immediately  below  the  infra-orbital  fora- 
men.    It  is  inserted  narrow  into  the  angle  of  the  mouth. 

3.  Depressor  Labii  Inferiot'is,  arises  from  the  side  and  front 
of  the  inferior  maxilla  at  its  base,  and  is  inserted  into  the  greater 
part  of  the  lower  lip. 

4.  Depressor  Anguli  Oris,  arises  broad  and  fleshy  from  the 
base  of  the  lower  jaw  at  the  side  of  the  chin.  It  is  inserted  into 
the  angle  of  the  mouth. 

5.  Zygomaticus  Major,  arises  long  and  narrow  from  the  malar 
bone,  near  the  zygomatic  suture.  It  is  inserted  into  the  angle 
of  the  mouth. 

6.  Zggomaticus  3Iinor,  arises  from  the  front  part  of  the  malar 
bone,  and  is  inserted  into  the  upper  lip,  above  the  angle  of  the 
mouth. 


30  ORGANS    OF   PREHENSION. 

This  muscle  is  sometimes  wanting,  and  is  occasionally  a 
simple  slip  from  other  muscles. 

Buccinator,  arises  from  the  pterygo-maxillary  ligament,  and 
from  the  alveolar  margin  of  upper  and  lower  maxillary  bones  as 
far  anteriorly  as  the  first  molar  or  last  bicuspid  tooth.  Its  fibres 
are  inserted  into,  or  become  confluent  with,  those  of  the  orbicu- 
laris oris. 

8.  Orbicularis  Oris.  This  muscle  has  no  bony  attachments : 
it  is  circular,  surrounds  the  mouth,  and  consists  of  two  layers 
of  fibres;  one  for  the  upper,  the  other  for  the  lower  lip,  which 
meet  at  the  angle  of  the  mouth. 

9.  Depressor  Lahii  Superioris,  arises  from  the  alveolar  pro- 
cesses of  the  incisive  and  canine  teeth ;  and  is  inserted  into  the 
upper  lip  and  side  of  the  ala  nasi. 

10.  Levator  Labii  Inferioris,  arises  from  the  alveolar  processes 
of  the  incisive  teeth  of  the  lower  jaw.  It  is  inserted  into  the 
lower  lip  and  chin. 

See  Organs  of  Mastication  for  a  description  of  the  bones  con- 
nected with  these  muscles. 


CHAPTER    SECOND. 
ORGANS  OF  MASTICATION. 

Mastication,  as  the  term  implies,  is  a  process  of  chewing  or 
minutely  dividing  the  food,  when  introduced  into  the  mouth; 
and  the  organs  under  this  head  are  the  agents  or  instruments 
which  eflfect  this  operation. 

The  organs  of  mastication  are  divided  into,  1st.  The  passive : 
2d.  The  active. 

PASSIVE  ORGANS  OF  MASTICATION. 

The  passive  organs  include  the  bones,  ligaments  and  teeth. 
The  principal  bones  are, 

1.  The  superior  maxillary  or  upper  jaw  bones. 

2.  The  inferior  maxillary  or  lower  jaw  bone. 

3.  The  palate  bones. 

THE    SUPERIOR    MAXILLARY  BONES. 

The  Superior  Maxillary  Bones,  two  in  number,  are  in  pairs 
and  united  on  the  median  line  of  the  face.  They  occupy  the 
anterior  upper  part  of  the  face,  are  of  very  irregular  form,  and 
consist  of  a  body  and  processes. 

The  body  is  the  central  part  of  the  bone  and  has  four  sur- 
faces, namely,  the  anterior  or  facial,  the  posterior  or  pterygoid, 
the  superior  or  orbital,  and  the  inferior  or  palatine. 

The  Anterior  Surface  is  irregularly  convex,  and  has  a  depres- 
sion about  its  centre  just  above  the  canine  and  first  bicuspid 
teeth,  called  the  canine  fossa :  immediately  above  which  is  the 
infra-orbital  foramen  for  transmitting  an  artery  and  nerve  of 
same  name :  its  upper  and  inner  edge  forms  part  of  the  lower 
margin  of  the  orbit,  from  the  inner  extremity  of  which  proceeds 
upward  towards  the  nasal  and  frontal  bones  a  long  and  rather 
flat  process,  having  a  pyramidal  form — the  nasal  process  of  the 
superior  maxilla :  its  posterior  edge  forming  the  internal  margin 


32 


ORGANS   OF    MASTICATION. 


of  the  orbit  and  helping  to  form   the  hichrymal  groove;    its 
anterior  edge  receives  the  cartilages  of  the  nose ;  its  upper  cor- 

Fio.  2.  Fig.  3. 


Fig.  4. 


Fig.  2.  a  The  body  of  the  left  superior  maxilla:  h  Canine  fossa;  c  Infra-orbital  foramen; 
i  Incisive  fossa  ;  «  Harmonial  suture  of  the  two  bones;  /  Xasal  spine;  g  Semilunar  notch  of 
anterior  nares;  ft  Jfasal  process;  i  Articulation  with  lachrymal  bone  ;j  Malar  process;  fe  Tuberosity 
of  superior  maxilla;  /  Cavity  of  the  antrum  ;  to  Lachrymal  tubercle;  n  Orbital  process. 

Fifi.  3.  a  Nasal  surface  of  left  superior  maxilla ;  h  Opening  of  antrum  ;  c  Inferior  turbinated 
bone;  d  Inferior  meatus  of  nose  into  which  the  nasal  duct  opens;  «  Xasal  process ; /Semilunar 
notch  of  lachrymal  bone  ;  g  Nasal  spine;  ft  ft  Palate  process ;  i  i  Alveolar  process ;  j  Horizontal 
plate  of  palate  bone  ;  k  Palate  spine;  I  Tuberosity  of  palate  bone;  m  Hamular  process. 

responds  to  the  nasal  bones,  and  its  summit  to  the  frontal ;  while 
its  outer  surface  gives  attachment  to  muscles,  and  its  inner 
enters  into  the  formation  of  the  nose. 

From  the  lower  edge  of 
its  anterior  surface,  the  al- 
veolar processes  and  cavities 
are  formed :  these  consist 
in  depressions  of  a  more  or 
less  conical  form,  and  cor- 
respond to  the  number  of 
teeth,  or  roots  of  teeth, 
which  they  are  intended  to 
receive.  See  Fig.  4. 
The  bottom  of  each  of  these  cavities  is  perforated  by  a  small 
foramen,  for  the  passage  of  nerves  and  blood  vessels  which  supply 
the  teeth.  The  alveolar  border  externally  presents  a  fluted  ap- 
pearance ;  the  projections  correspond  with  the  alveolar  cavities, 
and  the  depressions  with  the  septa  which  divide  them  from  one 
another. 


The  Posterior  Surface  has  a  bulging,  called  tuberosity,  which 


ORGANS    OF    MASTICATION.  33 

is  connected  with  the  palate  bones,  and  bounds  the  antrum 
behind;  it  is  perforated  by  three  or  four  small  holes — the  poste- 
rior dental  canals  which  transmit  nerves  and  blood  vessels  to  the 
molar  teeth. 

The  Lower  Surface  extends  from  the  alveolar  processes  in 
front  to  the  horizontal  plate  of  the  palate  bones  behind,  called 
the  palatine  processes,  which  are  rough  below,  forming  the  roof 
of  the  mouth,  and  smooth  above,  making  the  floor  of  the  nostrils. 
They  are  united  along  the  median  line,  at  the  anterior  part  of 
which  is  the  foramen  incisivum,  having  two  openings  in  the  nares 
above,  while  there  is  but  one  in  the  mouth  below. 

The  Upper  or  Orbital  Surface  is  triangular  in  shape,  with  its 
base  in  front  forming  the  anterior,  lower  and  internal  edge  of 
the  orbit ;  while  its  apex  extends  back  to  the  bottom,  forming 
the  floor  of  the  orbit  and  roof  of  the  antrum ;  its  internal  edge  is 
united  to  the  lachrymal,  ethmoid,  and  palate  bones;  its  external 
edge  assists  in  forming  the  spheno-maxillary  fi&sure,  and  along 
its  central  surface  is  seen  a  canal  running  from  behind,  forward 
and  inward — the  infra-orbital  canal.  This  canal  divides  into 
two :  the  smaller  is  the  anterior  dental,  which  descends  to  the 
anterior  alveoli  along  the  front  wall  of  the  antrum ;  the  other  is 
the  proper  continuation  of  the  canal  and  ends  at  the  infra-orbital 
hole  ;  along  the  upper  part  of  the  line  uniting  the  palatine  pro- 
cesses there  is  a  ridge,  the  nasal  crest,  for  receiving  the  vomer, 
and  at  the  anterior  part  of  this  crest  there  is  a  forward  projection, 
the  nasal  spine  ;  at  the  external  and  upper  part  of  the  body  is 
the  malar  process,  which  articulates  with  the  malar  bone.  This 
point  is  opposite  the  summit  of  the  maxillary  sinus. 

The  body  of  the  superior  maxilla  is  occupied  by  a  large  and 
very  important  cavity  called  the  Antrum  Highmorianum,  or 
Maxillary  Sinus.  This  cavity  is  somewhat  triangular  in  shape, 
with  its  base  generally  looking  to  the  nose,  and  its  apex  to  the 
malar  process.  Its  upper  wall  is  formed  by  the  floor  of  the 
orbit,  its  lower  by  the  alveoli  of  the  molar  teeth,  which  some- 
times perforate  this  cavity.  The  canine  fossa  bounds  it  in  front, 
while  the  tuberosity  closes  it  behind.  But  the  shape  of  this 
cavity  is  exceedingly  variable.     In  examining  a  collection  of 


84  ORGANS    OF    MASTICATION. 

nearly  one  hundred  maxillae  in  the  Museum  of  the  Baltimore 
Dental  College,  no  two  sinuses  were  found  to  he  shaped  alike, 
and  this  diflference  is  as  marked  between  the  right  and  the  left 
in  the  same,  as  in  different  subjects.  The  floor  of  some  is  nearly 
flat,  but  in  the  majority  of  cases  it  is  very  uneven;  sometimes 
crossed  by  a  single  septum,  varying  from  one-eighth  to  half  an 
inch  in  height:  at  other  times  there  are  found  three  or  four  septa, 
dividing  the  lower  part  of  the  cavity  into  as  many  separate  com- 
partments, with  the  bottom  or  floor  of  no  two  on  a  level  with 
each  other.  Some  are  perforated  by  the  roots  of  one  or  more 
teeth  ;  at  other  times  the  roots  of  several  teeth  extend  consider- 
ably above  the  level  of  the  floor  of  the  antrum  covered  by  a 
lamina  of  bone  scarcely  thicker  than  bank  note  paper.  In  other 
cases,  the  floor  of  the  antrum  is  half  an  inch  above  the  extremi- 
ties of  the  roots  of  the  teeth.  This  cavity  also  varies  as  much 
in  size  as  it  does  in  shape. 

The  opening  of  the  antrum  is,  on  its  nasal  portion  or  base, 
into  the  middle  meatus  of  the  nose ;  in  the  skeleton  it  is  large, 
while  in  the  natural  state  it  is  much  contracted  by  the  ethmoid 
bone  above,  the  inferior  turbinated  bone  below,  the  palate  bone 
behind,  and  by  the  mucous  membrane  which  passes  through  the 
opening  and  lines  the  interior  of  the  antrum. 

The  structure  of  the  upper  jaw,  with  its  alveolar  and  nume- 
rous other  processes,  is  thick  and  cellular ;  the  cancellated 
structure  being  invested  with  a  thin  layer  of  compact  bone. 

It  is  articulated  with  two  bones  of  the  cranium,  the  frontal 
and  ethmoid,  and  seven  of  the  face,  namely :  the  nasal,  malar, 
lachrymal,  palate,  inferior  turbinated,  vomer,  and  to  its  fellow,  by 
sutures;  also  to  the  teeth  by  the  articulation  termed  gomphosis. 

Its  development  commences  at  so  early  a  period  of  intra-uterine 
life,  and  ossification  proceeds  so  rapidly,  that  the  number  of 
ossific  centres  is  uncertain  :  some  give  a  centre  for  the  body  and 
each  process,  others  think  that  most  probably  there  are  but  four 
centres  in  all.  It  may  be  seen  as  early  as  the  thirty-fifth  or 
fortieth  day  after  conception ;  and  although  at  birth  it  has 
acquired  but  little  height,  it  has  increased  considerably  in 
breadth.  But,  at  this  period,  the  alveolar  border,  which  con- 
stitutes the  largest  portion  of  the  bone,  is  almost  in  contact 
with  the  orbit.     The  antrum  is  still  scarcely  perceptible,  but  as 


ORGANS    OF    MASTICATION.  35 

the  vertical  dimensions  of  the  bone  are  increased,  it  is  gradually 
developed.  With  the  loss  of  the  teeth,  the  alveolar  border 
nearly  disappears,  so  that  the  vault  of  the  palate  loses  its 
arched  form,  and  sometimes  becomes  almost  flat. 

INFERIOR   MAXILLARY    BONE. 

Fm.  5. 


Fig.  6.  The  Inferior  maxilla :  a  Body  of  the  bone ;  h  Mental  foramen  ;  c  The  symphysis ; 
A  d  Alveolar  processes ;  e  Ramus  of  the  lower  jaw  ;  /  Its  angle  ;  g  g  Coronoid  processes  ;  h  h 
Sigmoid  notch;  ii  Condyloid  processes ;  j' .7  Neck  of  the  condyles;  k  Inferior  dental  foramen  ; 
I  Mylo-hyoid  ridge. 

The"  Lower  Jaw^  Fig.  5,  is  the  largest  bone  of  the  face,  and 
though  single  in  the  adult,  it  consists  of  two  symmetrical  pieces 
in  the  foetus. 

It  occupies  the  lower  part  of  the  face,  has  a  parabolic  form, 
and  extends  backwards  to  the  base  of  the  skull. 

It  is  divided  into  a  body  and  extremities. 

The  body  is  the  middle  and  horizontal  portion ;  this  is  divided 
along  its  centre  by  a  ridge  called  the  symphysis,  which  is  the 
place  of  separation  in  the  infant  state;  the  middle  portion 
projects  at  its  inferior  part  into  an  eminence  called  the  mental 
process  or  chin ;  on  each  side  of  which  is  a  depression  for  the 
muscles  of  the  lower  lip,  and  externally  to  these  depressions  are 
two  foramina,  called  anterior  mental,  for  transmitting  an  artery 
and  nerve  of  the  same  name. 

The  horizontal  portions  extend  backward  and  outward;  and 


36 


ORGANS   OF    MASTICATION. 


on  the  outward  surface  have  an  oblique  line  for  the  attachment 
of  muscles. 

On  the  inner  surface  of  the  middle  part  behind  the  chin,  along 
the  line  of  the  symphysis,  there  is  a  chain  of  eminences  called 
genial  processes ;  to  the  superior  of  which  the  frenum  linguae  is 
attached,  to  the  middle  the  genio-hyo-glossi,  and  to  the  inferior 
the  genio-hyoid  muscles;  on  each  side  of  these  eminences  are 
depressions  for  the  sublingual  glands ;  and  beyond  these  depres- 
sions there  runs  an  oblique  ridge  upward  and  outward,  to  the 
anterior  part  of  which  is  attached  the  mylo-hyoid  muscle,  and  to 
the  posterior  part,  the  superior  constrictor  of  the  pharynx ;  this 
latter  muscle  is  consequently  involved  more  or  less  in  the  extrac- 
tion of  the  last  molar  tooth.  Below  this  line  there  is  a  groove 
for  the  mylo-hyoid  nerve. 

The  upper  edge  of  the  bod}-  is  surmounted  by  the  alveolar 
processes  with  cavities,  corresponding  in  number  and  size  to  the 
roots  of  the  teeth.  (See  Fig.  6.)     The  alveolar  border,  in  the 

Fig.  6. 


foetus,  constitutes  nearly  the  whole  body  of  the  bone.  After 
the  loss  of  the  teeth,  this  part  of  the  inferior  maxillary  is 
gradually  wasted.  The  alveolar  border,  in  the  lower  jaw, 
describes  a  rather  smaller  arch  than  it  does  in  the  upper,  and 
both  its  anterior  walls  are  thinner  than  the  posterior. 


ORGANS    OF    MASTICATION.  37 

The  lower  edge,  called  the  base,  is  rounded  and  obtuse,  and 
is  invested  by  the  superficial  fascia  and  platysma-myoid  muscle. 

The  extremities  of  the  body  have  two  large  processes  rising 
up  at  an  obtuse  angle,  named  the  ?'ame  of  the  lower  jaw.  These 
processes  are  flat  and  broad  on  their  surfaces;  the  outer  one  is 
covered  by  the  masseter  muscle ;  the  inner  one  has  a  deep  groove 
which  leads  to  a  large  hole,  the  posterior  dental  or  maxillary 
foramen,  for  transmitting  the  inferior  dental  nerves  and  vessels 
to  the  dental  canal  running  along  the  roots  of  the  teeth.  This 
foramen  is  protected  by  a  spine  to  which  the  spheno-maxillary 
ligament  is  attached. 

The  ramus  has  a  projection  at  its  lower  part  which  is  the  angle 
of  the  lower  jaw ;  its  upper  ridge  is  curved,  having  a  process  at. 
each  end — the  anterior  one  is  the  coronoid  process ;  this  is  trian- 
gular, and  has  the  temporal  muscle  inserted  into  it;  the  posterior 
is  the  condyloid,  and  articulates  with  the  temporal  bone.  This 
process  has  a  neck  which  receives  the  insertion  of  the  external 
pterygoid  muscle. 

The  structure  of  the  inferior  maxilla  is  compact  externally, 
cellular  within,  and  traversed  in  the  greater  part  of  its  extent 
by  the  inferior  dental  canal. 

The  lower  jaw  is  developed  from  two  centres  of  ossification, 
which  meet  at  the  symphysis.  It  articulates  on  each  side  by 
one  of  its  condyles  with  the  glenoid  cavity  of  the  temporal  bone, 
situated  at  the  base  of  the  zygomatic  process.  This  cavity 
is  divided  into  two  portions — an  anterior  and  a  posterior.  The 
former  constitutes  the  articular  portion,  the  latter  lodges  a 
process  of  the  parotid  gland.  The  two  are  separated  by  the 
fissure  of  Glasserius,  fissura  Glasserii,  which  transmits  the  chorda 
tympani  nerve,  the  laxator  tympani  muscle  and  the  anterior 
tympanic  artery.  It  also  gives  lodgement  to  the  long  process, 
frocessus  gracilis,  of  the  malleus. 

Between  this  cavity  and  the  condyle,  there  is  interposed  an 
interarticular  cartilage,  so  moulded  as  to  fit  the  two  articular 
surfaces.  The  circumference  of  this  being  free,  except  where 
it  adheres  to  the  external  lateral  ligament  and  affords  attach- 
ment to  a  few  fibres  of  the  external  pterygoid  muscle,  facilitates 
the  movements  of  the  joint. 

The  union  of  this  articulation  is  maintained  by  the  external 


38  ORGANS    OF    MASTICATION. 

lateral,  the  spheno-maxillarv,  and  the  stylo-maxillary  ligaments. 
The  external  lateral  is  seen  in  Fig.  32. 

THE  PALATE  BONES. 

The  palate  bones,  two  in  number,  are  situated  at  the  back 
part  of  the  superior  maxillary  bone,  between  its  tuberosities  and 
the  pterygoid  processes  of  the  sphenoid  bone.     They  are  alike. 

The  palate  bone  is  divided  into  three  plates :  the  horizontal 
or  palatine,  the  vertical  or  nasal,  and  the  orbital. 

The  palate  plate  is  broad  and  on  the  same  line  with  the  palate 
processes  of  the  superior  maxillary  bone;  its  upper  surface  is 
smooth  and  forms  the  posterior  floor  of  the  nostrils,  the  lower 
surface  is  rough  and  forms  the  posterior  part  of  the  roof  of  the 
mouth;  its  anterior  edge  is  connected  with  the  palate  process  of 
the  upper  jaw,  and  its  posterior  is  thin  and  crescentic,  to  which  is 
attached  the  velum-pendulum  palati  or  soft  palate ;  at  the  pos- 
terior point  of  the  suture,  uniting  the  two  palate  bones,  there 
projects  backward  a  process  called  the  posterior  nasal  spine, 
which  gives  origin  to  the  azygos-uvulae  muscle.  The  vertical 
plate  ascends,  helps  to  bound  the  nasal  cavity,  diminishes  the 
opening  into  the  antrum  by  projecting  forward,  and  by  its 
external  posterior  part,  in  conjunction  with  the  pterygoid  pro- 
cesses of  the  sphenoid  bone,  forms  the  posterior  palatine  canal ^ 
the  lower  orifice  of  which  is  seen  on  the  mai'gin  of  the  palate 
plate,  and  is  called  the  posterior  palatine  foramen,  transmitting 
the  palatine  nerve  and  artery  to  the  soft  palate;  behind  this 
foramen  is  often  seen  a  smaller  one,  passing  through  the  base  of 
the  pterygoid  process  of  this  bone,  and  sending  a  filament  of 
the  same  nerve  to  the  palate. 

The  upper  end  of  the  vertical  or  nasal  plate  has  two  pro- 
cesses— the  one  is  seen  at  the  back  of  the  orbit,  called  the 
orbital  process;  the  other  is  posterior  and  fits  against  the  under 
surface  of  the  body  of  the  sphenoid  bone.  Between  these  two 
processes  is  a  foramen,  the  spheno-palatine,  which  transmits  to 
the  nose  a  nerve  and  artery  of  the  same  name. 

The  palate  bone  articulates  with  six  others,  namely:  the 
superior  maxillary,  inferior  turbinated,  vomer,  sphenoid,  eth- 
moid, and  opposite  palate. 


ORGANS    OF    MASTICATION. 


39 


The  structure  of  this  bone  is  very  thin,  and  consists  almost 
entirely  of  compact  tissue.  Its  development,  it  is  said,  takes 
place  by  a  single  point  of  ossification  at  the  union  of  the  vertical, 
horizontal  and  pyramidal  portions. 


Fig.  7. 


FiQ.  7.  Posterior  view  of  the  palate  bone  ia  its  natural  position,  except  that  it  is  turned  a  little 
to  one  side  so  as  to  show  the  internal  surface  of  its  perpendicular  plate  ;  a  Nasal  surface  of 
horizontal  plate;  b  Nasal  surface  of  perpendicular  plate;  ckl  Pterygoid  process  or  tuberosity; 
d  Broad  internal  border  of  horizontal  plate,  which  articulates  with  same  border  of  opposite  bone; 
/  Process  which  unites  with  the  same  ou  the  opposite  side  to  form  the  nasal  spine ;  g  Hori- 
zontal ridge  which  gives  attachment  to  inferior  turbinated  bone;  h  Spheno-palatine  foramen; 
i  Orbital  portion  ;  j  Pterygoid  apophysis. 

Fig.  8.  Spheno-maxillary  surface  of  perpendicular  plate  of  palate  bone ;  a  Its  rough  surface, 
or  the  one  which  articulates  with  superior  maxillary  bone;  b  Part  of  the  posterior  palatine 
canal;  c  Spheno-palatine  foramen;  d  Spheno-maxillary  facet;  e  Orbital  facet;  /Maxillary 
facet ;  g  Sphenoidal  portion  of  perpendicular  plate  ;  h  Tuberosity  of  the  ba.se  or  pterygoid  process. 

The  bones  of  the  Head  are  twenty-two  in  number,  of  which 
eight  compose  the  cranium  and  fourteen  the  face.  Those  of  the 
cranium  are  one  frontal,  two  parietal,  two  temporal,  one  occi- 
pital, one  sphenoid  and  one  ethmoid.  Those  of  the  face  are  six 
pairs  and  two  single  bones;  the  pairs  are  the  two  malar,  two 
superior  maxillary,  two  lachrymal,  two  nasal,  two  palatine  and 
two  inferior  turbinated.  The  vomer  and  inferior  maxillary  are 
the  two  single  bones. 


THE  TEETH. 

The  teeth  are  the  prime  organs  of  mastication,  are  the 
hardest  portions  of  the  body,  and  are  implanted  in  the  alveolar 
cavities  of  both  the  upper  and  lower  jaw.  Although  analogous 
in  structure  to  bone,  they  are  regarded,  by  some,  from  their 
mode  "of  development,  as  a  modification  of  mucous  membrane. 

A  tooth  is  composed  of  four  distinct  structures:  1.  The 
pulp,  occupying  the  chamber  in  the  crown  and  the  canal  extend- 
ing through  the  root ;    2.  The  dentine,  which  constitutes  the 


40 


ORGANS    OF    MASTICATION. 


Fig.  9. 


principal  part  of  the  organ  ;  3.  The  enamel,  which  forms  the 
covering  and  protection  of  the  crown ;  4. 
The  cein^ntum  or  crusta  petrosa,  which 
covers  the  root.    (See  Fig.  9.) 

The  teeth  of  first  dentition,  termed  the 
milk,  temporary,  or  deciduous  teeth,  are 
designed  merely  to  supply  the  wants  of 
childhood,  and  are  replaced  with  a  larger, 
stronger  and  more  numerous  set.  These 
are  termed  the  permanent  or  adult  teeth, 
and  are  intended  to  continue  through  life. 
The  anatomical  divisions  of  a  tooth  are  : 
1.  The  crown  or  exposed  part  situated 
above  the  gum  ;  2.  The  root  occupying 
the  alveolar  cavity  or  socket ;  3.  The  neck 
which  is  the  constricted  portion  between 
^^  crown  and  root. 

THE    TEMPORARY    TEETH. 

The  temporary  teeth  are  divided  into 
three  classes :  first,  the  incisors  ;  second, 
Fio  9  a  The  coroQai  surface    the  cuspids  or  cauinc  tccth ;    third,  the 

divested  of  enamel;  6  Tbe  (leu-  '  ' 

rlmin''.,'!'.!!''  Vl^,  T''^,' ''  '^^^    molnYs,  whlch  are  succeeded  by  the  biscus- 

cemeatum,  or  crusta  petroiia ;  e  '  J  m 

The  enamel.  ^j^l^  ^^  premolars. 


Fig    11. 


Flo.  10.    Front  or  labial  view  of  the  temporary  teeth  of  the  left  side. 
Fio.  11.    Palatine  or  lingual  view  of  those  on  the  right  side. 

The  temporary  teeth  are  twenty  in  number,  ten  in  each  jaw, 
namely  :  four  incisors,  two  cuspids,  and  four  molars. 


OR(iANS    OF    MASTICATION. 
FtG.  12.  Fig.   13. 


41 


Fig.  12.    Lateral  or  side  view  of  temporary  teeth. 
Fig.  13.    Section  of  ditto,  exposing  their  pulp  cavities. 

The  pulp  cavity  in  a  temporary  tooth  is  larger  in  proportion 
to  the  size  of  the  organ  than  in  a  permanent  tooth. 

THE    PERMANENT    TEETH. 

There  are  thirty-two  teeth  in  the  permanent  set,  sixteen  to 
each  jaw — being  an  increase  of  twelve  over  the  temporary, 
designated  as  follows :  incisors,  four  ;  cuspids,  two  ;  bicuspids  or 
premolars,  four ;  molars,  six — in  each  jaw.  The  third  or  last 
molar  is  sometimes  denominated  dens  sapientice  or  wisdom  tooth. 

THE    PULP. 

The  pulp,  occupying  the  pulp  cavity  in  the  centre  of  the  tooth, 
is  the  shrunken  condition  to  which  the  tooth-germ  is  permanently 


Fig    14. 


Fig    15. 


Fro    H.    A  portion  of  the  body  of  tlie  pulp,  showing  the  cellular  arrangement. 
*  hi.  lo.    A  portion  of  the  superficial  layer  of  the  pulp,  showing  the  appearance 


nee  of  vesicles. 


reduced  after  it  has  normally  accomplished  the  work  of  dentin ifi- 
cation.    It  is  an  exquisitively  sensitive,  highly  vascular  substance, 
4 


42  ORGANS    OF    MASTICATION. 

of  a  reddish-gray  color,  enveloped  in  an  exceedingly  delicate,  and 
apparently  structureless  membrane,  continuous  with  the  alveolo- 
dental  periosteum,  and  adherent  to  the  walls  of  the  pulp  cavity. 
This  is  designated  by  Mr.  Thomas  Bell  "  the  proper  membrane 
of  the  pulp,"  and  by  Purkinje  and  Raschkow,  "the  preformative 
membrane;"  because,  in  the  formation  of  the  dentine,  the  deposi- 
tion of  earthy  salts,  according  to  these  authors,  commences  in  it. 
Fig.  16.  The    pulp,   according    to   the   two   last 

mentioned  i^uthors,  is  composed  of  minute 
globules.  Schwann  describes  it  as  con- 
sisting of  globular  nucleated  cells,  with 
vessels  and  nerves  passing  between  them, 
the  cells  having  the  same  radial  course 
as  the  fibres  of  the  dentine.  According 
to  the  microscopic  observations  of  Mr. 
Fig.  16.  A  portion  of  the  body     Nasmvth,  it   is   principally   composed   of 

of  the  pulp,  showing  another  ■' 

variety  in  the  arrangement  of      minute     VCSicular     CcUs,     Varying     in     sizC 

the  cells.  '  "^      ° 

from  the  ten-thousandth  to  the  one-eighth 
of  an  inch  in  diameter,  disposed  in  concentric  layers ;  these, 
when  macerated,  have  an  irregular  reticulated  appearance,  and 
are  found  to  be  interspersed  with  granules,  the  parenchyma  being 
traversed  by  vessels  having  a  vertical  direction.  See  Figs.  14, 
15  and  16,  copied  from  Mr,  Nasmyth's  Researches  on  the  De- 
velopment and  Structure  of  the  Teeth. 

Mr.  Tomes  describes  it  as  consisting,  from  its  earliest  appear- 
ance, of  a  series  of  nucleated  cells,  united  and  supported  by 
plasma ;  also,  prior  to  the  commencement  of  the  formation  of  the 
dentine,  of  delicate  areolar  tissue,  occupied  by  a  thick,  clear, 
homogeneous  fluid  or  plasma.  The  pulp  is  liberally  supplied 
with  blood-vessels,  furnished  by  the  trunk  which  enters  its  base. 
The  ramifications  of  these  vessels  are  distributed  throughout  its 
entire  substance,  forming  a  capillary  net-work  which  terminates 
in  loops  upon  its  surface. 

The  distribution  of  the  vessels  of  the  pulp  is  represented  in 
Fig.  17,  copied  from  the  late  work  of  Mr.  Nasmyth,  and  made 
from  an  injected  preparation  of  an  upper  central  incisor.  The 
communication  of  the  arteries  with  the  veins  by  means  of  a  series 
of  looped  capillaries,  presenting  a  densely  matted  appearance 


ORGANS    OF    MASTICATION. 


43 


upon  the  surface,  are  here  beautifully  represented.  The  nerves 
of  the  pulp  have  a  very  sin^ilar  arrangement  in  their  distribution, 
having  apparently  looped  terminations  (Fig.  18). 


Fig.  17. 


Fio.  17.    a  The  vessels  of  the  pulp  of  an  upper  central  incisor  injected,  as  seen  under  the  micro- 
scope, very  highly  magnified ;  b  The  nat'iral  size  of  the  pulp. 


Kollikcr  describes  the  pulp  as  consisting  of  an  indistinctly 
fibrous  connective  tissue,  containing  many  dispersed,  rounded 
and  elongated  nuclei ;  with,  occasionally,  narrow  bundles,  some- 


44 


ORGANS    OF    MASTICATION. 


Fig.   18. 


what  like  imperfect  foetal  connective  tissue,  filled  with  a  fluid 

substance.  Immediately  beneath  the 
structureless  membrane  in  which  these 
tissues  are  inclosed,  there  is  a  layer 
composed  of  many  series  of  cells,  cylin- 
drical or  pointed  at  one  end,  with  long 
and  narrow  nuclei,  arranged  perpen- 
dicularly to  the  surface  of  the  pulp, 
like  a  cylinder  of  epithelium.  This 
layer  is  described  as  being  from  two  to 
four  one-hundredths  of  a  line  in  thick- 
ness. These,  in  regular  series  proceed- 
ing internally,  become  less  and  less 
di.'^tinct ;  '*but  the  cells,  without  losing 
their  radial  arrangement,  are  more  in- 
termixed, and  pass  finally,  by  shorter 
and  rounder  cells,  without  any  sharp 
line  of  demarkation,  into  the  vascular 
tissue  of  the  pulp."  His  description 
of  the  distribution  of  the  vessels  and 
nerves  of  the  pulp  is  similar  to  that 
given  by  Mr.  Nasmyth  and  Mr.  Tomes. 
The  pulp,  previous  to  the  formation 
„„,„„.  ,.,       ,     ,  of  the  dentine,  is  inclosed  in  a  sac, 

Fio.  18.    The  nerves  of  the  pulp  of  '  ' 

twen"y'diamet"ers."""^''^'  "'"^"'^^'^  consistiug  of  two  lamiufc,  au  outcr  and 

an  inner.  The  former  is  described  by 
Mr.  Hunter  as  being  soft  and  spongy,  and  without  vessels ;  the 
latter  as  being  extremely  vascular  and  firm.  Mr.  Thomas  Bell, 
on  the  other  hand,  contends  that  the  outer  i&  more  tender  and  full 
of  vessels,  while  the  inner  is  destitute  of  them  ;  and  this  opinion 
is  supported  by  the  microscopic  researches  of  Mr.  Nasmyth,  who 
descril)es  the  internal  lamina  of  the  capsule,  previous  to  its  clos- 
ing and  forming  a  sac,  as  possessing  no  vessels,  though  the  injec- 
tions of  Mr.  Fox  would  seem  to  prove  the  contrary.  But  as  the 
author  will  again  have  occasion,  when  he  treats  of  the  origin  and 
formation  of  the  teeth,  to  recur  to  this  subject,  he  Avill  not  enlarge 
upon  it  in  this  place. 


OKGANS    OF    MASTICATION. 


45 


THE    DENTINE, 

The  dentine  [b  Fig.  9)  is  a  very  hard,  dense  substance,  con- 
stituting the  inner  and  larger  portion  of  the  crown  and  nearly 
the  whole  of  the  root  of  the  tooth.  It  consists  of  earthy  salts 
and  animal  matter.  The  former  may  be  removed  by  the  action 
of  acids,  leaving  the  latter  entire  ;  by  subjecting  to  a  strong  heat, 
the  animal  portion  may  be  destroyed,  leaving  the  earthy. 

Fig.   19. 


Fig.  20. 


Fio.  1!).  Deatine  and  ceinentum  frurn  tlie  root  of  a  human  incisor,  copied  from  Kolliker:  a 
Dentinal  fibres  or  tubes  ;  b  Interglobular  spaces,  havina  the  appearance  of  the  lacuna  in  bone  ; 
c  Smaller  interglobular  spacp,> ;  d  Commencement  of  the  cementum,  with  numerous  canals  close 
together;   e  Its  lamellce ;  /Lacuna;   g  Canals. 

Dentine  is  harder  than  bone  or  cementum,  but  less  dense  than 
enamel.  It  is,  apparently,  disposed  in  concentric  layers,  arranged 
one  Avithin  the  other,  parallel  to  the  surface  of 
the  tooth — the  last  internal  layer  forming  the 
boundary  of  the  pulp-cavity.  But  in  addition 
to  this  peculiar  structural  arrangement,  it  is, 
according  to  the  microscopic  observations  of 
Purkinje,  Retzius,  and  Miiller,  composed  of 
minute  tubes  or  hollow  fibres,  radiating  from 
the  pulp-cavity  to  the  periphery  of  the  tooth, 
giving  off,  in  their  course,  numerous  branches, 
as  seen  in  Fig.  19,  sometimes  terminating  in 
small  cells  or  corpuscles;  and  an  amorphous  p,„  o,,.  Transverse sec- 
or  structureless  intertubular  substance.  The  l'!:"  LVu^e^roo; o'^CLau 
doctrine  of  the  tubularity  of  dentine  is  also  lers,'si?owiDgTheir'nui"r- 

,     •        T     1  , 1  ,  ,  1  p  ous  anastomoses. 

sustained    by    the    subsequent   researches   oi 

Professor  Owen,  Mr.  Tomes,  Kolliker  and  several  other  micro- 

scopists;    while  on   the  other   hand,   Mr.   Alexander  Nasmyth, 


46 


ORGANS    OF    MASTICATION. 


FiCx.  21. 


equally  distinguished  as  an  odontologist,  has  seemingly  demon- 
strated, by  a  series  of  beautiful  and  highly  interesting  experi- 
ments, that  the  canaliculi  or  tubes  of  these  authors,  are  solid 
fibres  "  composed  of  a  series  of  little  masses,  succeeding  each 
other  in  a  linear  direction,  like  so  many  beads  collected  on  a 
string."     See  Fig.  21. 

This  appearance,  however,  which  is  not  always  conspicuous  in 
the  human  dentine,  but  is  more  remarkable  in  that  of  monkeys, 
ought  not  to  mislead  the  observer:  for  the  tubular  character  of 
the  so-called  "dentine  fibres,"  whether  simple  or  baccated,  may 
be  demonstrated  in  their  microscopic  sections,  which,  when  dry  or 
properly  mounted  in  Canada  Balsam,  exhibit  the  canaliculi  filled 
with  air  as  black  lines ;  or  when  moistened  with  turpentine  or 
thin  balsam  allow  the  fluid  to  be  seen  to  penetrate  int©  the  tubules,, 
expel  the  air,  and  render  the  whole  section  extremely  transparent. 
The  tubes  radiate  from  the  pulp-cavity  to  the  outer  surface  of 
the  dentine,  each  tube  making,  in  its  course,  three  principal  or  pri- 
mary curves,  and  presenting,  when  ex- 
amined with  a  high  magnifying  power, 
numerous  secondary  undulations,  which 
are  less  perceptible  at  the  external  ex- 
tremity of  the  tubes  than  at  the  middle, 
and  still  less  in  the  temporary  than  in 
the  permanent  teeth.  The  diameter  of 
the  tubes,  from  their  commencement  to 
the  middle  of  the  outer  third  of  their 
course,  is  estimated  at  1-10, 000th  of  an 
inch ;  but  from  this  point  their  terminal 
branches  rapidly,  diminish  until  they 
become  invisible,  or  are  lost  in  small 
When  examined  under  a  magnifying 
power  of  from  three  to  five  hundred  diameters,  they  are  seen  to 
branch  by  a  dichotomous  division  and  in  their  Avhole  course  to 
give  off  numerous  lateral  branches.  The  tubes  are  not  mere  ex- 
cavations, but  have  special  parietes  ;  the  undulations  in  them  are 
ascribed  to  certain  periodic  movements  in  the  pulp  during  the 
formation  of  the  successive  layers  of  dentine,  and  both  Retzius 
and  Miiller  represent  them  as  containing  granular  masses  of  in- 
organic matter.* 

*  MuUer's  Physiology. 


Fio.  21.  The  nuclei  of  fibres  of 
dentine,  arranged  in  a  linear  series, 
as  shown  by  Mr.  Xasmyth. 


irregular  rounded  cells. 


ORGANS    OF    MASTICATION. 


47 


These  tubes  are  represented  as  piercing  every  part  of  the 
surface  of  the  pulp  cavity, 
being,  according  to  Pro- 
fessor Owen,  about  the 
ToVff  P'^'-rt  of  an  inch  in 
diameter ;  they  radiate  as 
before  stated,  from  the  in- 
ner to  the  peripheral  surface 

of    the    dentine.        "In     the      rm.  22.  Trausverse  section  of  dentinal  canals  as  they 

are  commonly  seen,  magnified  450  diameters :  a,  canals 

lower  incisive  and  canine  ^"""^  *=''''^  together ;  b,  more  dispersed. 
teeth,"  says  the  last  mentioned  author,  "those  from  the  middle 
of  the  summit  of  the  pulp  cavity,  ascend  vertically  to  the  enamel 
covered  surface  of  the  dentine  at  the  summit  of  the  crown  ;  the 
tubes  on  each  side  of  these  gradually  incline  outward ;  those 
which  go  to  the  angles  of  the  crown,  forming  an  angle  of  45° 
with  the  middle  vertical  tubes  ;  at  the  sides  of  the  crown  the 
tubes  incline  still  more  outward,  until  in  the  middle  of  the  fang 
they  become  horizontal,  and  still  lower,  bend  downward."* 
The  vertical  tubes  are  described  as  being  nearly  straight,  but  as 
they  begin  to  incline  downward,  they  present  two,  and  usually 
three  curves ;  at  the  sides  of  the  crown  and  the  upper  half  of 
the  root  they  have  a  short  concave  bend  toward  the  crown,  then 
a  longer  curve  in  the  opposite,  and,  finally,  a  third  curve  in  the 
first  direction,  but  having  a  general  concave  bend  downward. 
The  course  of  the  tubuli  may  be  seen  in  Fig.  9. 

The  secondary  curvatures  of  the  dentinal  fibres,  or  tubes, 
are  very  numerous ;  the  last  mentioned  author  says,  "  Two 
hundred  may  be  counted  in  an  extent  of  yV  of  an  inch ;  the 
curvatures  observed  in  these,  both  primary  and  secondary  are 
parallel."  Professor  Retzius  describes  certain  strice,  running 
parallel  with  the  pulp  cavity,  "  like  the  annual  rings  in  the 
trunk  of  a  tree."  These  circular  lines  are  rarely  seen  in  the 
dentine  of  human  teeth,  though  very  observable  in  some  animals, 
especially  the  elephant,  and  they  are  somewhat  similar  to  the 
contour  lines  of  Professor  Owen,  proceeding  from  "  a  short 
bend,"  occasionally  observed  in  the  tubes,  "  along  a  line  parallel 
with  the  crown." 

The  dentinal  fibres  of  the  crown,  in  the  teeth  of  the  human 
subject,  give  ofi"  but  few  branches,  until  they  arrive  nearly  at 

*  Owen's  Odontography. 


48  ORGANS    OF    MASTICATION. 

the  outer  surface  of  the  dentine  ;  the  ramifications  become  more 
and  more  numerous  towards  the  extremity  of  the  root,  and  here, 
too,  the  terminal  branches  anastomose  more  frequently  with 
each  otlier.  In  the  crown  they  pass  a  short  distance  into  the 
enamel,  and  terminate  in  small  cavities  near  the  surface  ;  and 
it  is  here,  or  immediately  upon  the  peripheral  surface,  that  den- 
tine is  most  sensitive.  These  cavities,  called  "enamel  cells"  by 
Professor  C.  Johnston  of  the  Baltimore  Dental  College,*  who 
has  the  merit  of  having  first  pointed  out  their  constancy  and 
probable  function,  are,  doubtless,  in  connection  with  the  nerves 
of  the  pulp,  and  lodge  a  portion  of  neurine. 

The  researches  of  Mr.  Nasmyth  into  the  structure  of  dentine, 
as  already  intimated,  do  not  accord  with  those  of  most  other  micro- 
scopists ;  he  found,  when  sections  made  parallel  to  the  fibres 
were  submitted  to  the  action  of  acid  until  the  earthy  salts  were 
all  taken  up,  that  the  animal  residue  consisted  of  solid  fibres, 
presenting  an  irregular  or  baccated  appearance  ;  being  composed 
of  numerous  separate  compartments  or  cells,  corresponding  ex- 
actly with  the  reticulations  observed  on  the  surface  of  the  pulp, 
previous  to  the  deposition  of  earthy  salts,  see  Fig.  21.  The 
sliape  and  size  of  tliese  cells,  he  describes  as  varying  in  different 
animals ;  in  the  human  tooth  as  being  oval,  and  as  having  their 
long  axis  corresponding  with  the  course  of  the  fibre,  the  ex- 
tremity of  each  being  in  apposition  with  the  one  adjoining. 

The  intertubular  tissue  constitutes  a  larger  portion  of  the 
dentine  in  the  root  than  in  the  crown  of  the  tooth,  an;l  is  sup- 
posed, by  Purkinj6,  Retzius,  Miiller,  Ktilliker,  and  other  equally 
distinguished  microscopists,  to  be  structureless.  Professor 
Oweti  and  Mr.  Nasmyth  describe  it  as  cellular.  Mr.  Tomes 
says,  "it  is  made  up  of  minute  granules,  closely  united."  Pro- 
fessor Kfilliker,  calls  it  the  matrix  of  the  canals,  or  tubules, 
and  affirms  that  it  is  "  homogeneous,"  "  without  cells,  fibres,  or 
other  elements."  The  "cells"  of  Owen  and  Nasmyth  are  described 
by  Czcrmdk,  Salter,  and  KiJlliker  under  the  appellation  "den- 
tine globules,"  of  which  the  limits  are  usually  indistinct,  but 
may  be  plainly  defined  by  intervening  spaces  of  dentine  partly 
or  completely  surrounding  them.  The  interglobular  spaces, 
as  Mr.  Salter  has  shown,  are  portions  of  imperfectly  "  calci- 
fied"  dentine ;   and  these,  together  with    the  globules,   which 

*  American  Journal  of  Dental  Science,  July,  1857,  p.  348. 


ORGANS    OF    MASTICATION.  49 

are  so  many  centres  of  dentine  "calcification,"  correspond  to  a 
phasis  of  dentinal  development,  and,  in  longitudinal  sections, 
create  in  a  tooth  the  appearance  of  stratification  indicated  by  his 
"contour  lines."  They  are  also  described  as  being  frequently 
pierced  by  the  tubuli.  The  smaller  spaces,  from  their  commu- 
nication with  the  tubules,  have  been  regarded  by  some  as 
identical  with  the  lacunse  of  bone.  But  Professor  Kolliker 
states  that  he  has  rarely  "  observed  actual  lacunse  in  normal 
dentine,"  and  when  present  they  were  always  at  the  boundary 
of  the  cement ;  but  "interglobular  spaces  and  dentinal  globules  " 
are  met  with  in  the  interior  of  the  root  and  on  the  walls  of  the 
pulp  cavity,  in  which  latter  place  they  give  rise  to  irregularities 
which  may  be  seen  with  the  naked  eye.  Again,  he  observes, 
"  The  interglobular  spaces  whose  presence  is  normal  in  develop- 
ing teeth,  contain,  during  life,  not  fluid,  as  might  at  first  be  ex- 
pected, but  a  soft  substance  resembling  tooth  cartilage  and  pos- 
sessins:  a  canaliculated  structure,  like  the  dentine  itself.  It  is 
remarkable  that  this  substance  offers  a  greater  resistance  to 
long  maceration  in  hydrochloric  acid  than  the  matrix  of  the 
actually  ossified  tooth,  and,  therefore,  like  the  dentinal  canals, 
it  may  be  completely  isolated.  In  sections,  this  interglobular 
substance  usually  dries  up  in  such  a  manner  that  a  cavity  is 
produced,  into  which  air  penetrates."  It  is  these,  according  to 
this  author,  which  constitute  the  interglobular  spaces,  but  there 
are  many  teeth  in  which  this  interglobular  substance  cannot  be 
detected,  where  delicate  arched  outlines  of  dentinal  globules 
may  be  observed. 

Mr.  Tomes  describes,  under  the  name  of  "  intermediate  sub- 
stance," a  granular  layer  near  the  surface  of  the  fang,  and  of 
which  the  uniting  medium  is  the  interglobular  substance  described 
by  Kolliker.  The  interspaces  have  the  appearance  of  cells, 
"granular  cells,"  and  he  also  states,  that  many  of  the  terminal 
tubes  communicate  with  these  granular  cells,  as  do  others, 
which  come  from  the  lacunne  of  the  cementum.  The  cells,  ac- 
cording to  this  author,  frequently  communicate  with  each  other, 
though  there  does  not  appear  to  be  any  special  provision  for 
such  communication. 

Most  microscopists  regard  dentine,  especially  that  of  human 
teeth,  as  destitute  of  vascular  canals,  but  the  author  has  seen 
ten  or  twelve  specimens  in  which  their  existence  Avas  so  clearly 


50  ORGANS    OF    MASTICATIOX. 

demonstrated  as  to  leave  no  room  for  doubt,  A  description  and 
drawing  of  one  of  these  he  published  in  the  second  volume  of 
the  American  Journal  of  Dental  Science.  A  similar  one  was 
shown  to  him  by  Dr.  Maynard,  of  Washington  City,  and  he  has 
a  section  of  a  molar  tooth  made  by  Dr.  Blandy,  in  which  several 
vessels  charged  with  red  blood  are  distinctly  seen.  Mr.  Tomes 
says  he  has  seen  eight  or  ten  sections  of  vascular  dentine,  and 
he  has  given  a  drawing  of  one  in  which  the  dentine  and  cementum 
are  both  pierced  by  vascular  canals.  The  occasional  and  ex- 
ceptional appearance  of  vascular  canals  in  human  dentine,  does 
not,  however,  justify  us  in  regarding  that  substance  as  normally 
vascular. 

The  delicate  sensibility  of  dentine,  especially  when  in  a  patho- 
logical condition,  seems  also  to  favor  the  opinion  that  nerve  fila- 
ments are  sent  from  the  pulp  to  every  part  of  this  tissue,  tra- 
versing, no  doubt,  the  tubuli,  which  extend  from  the  central 
chamber  to  the  periphery.  Several  years  ago  Dr.  Maynard 
stated  to  the  author  and  others  that,  in  removing  diseased  dentine 
preparatory  to  filling,  especially  from  the  side  of  a  tooth,  he  found 
that  his  patient  experienced  much  less  pain  when  he  applied  the 
excavator  to  the  part  nearest  the  root  and  cut  towards  the  coro- 
nal extremity,  than  when  excavating  in  the  opposite  direction. 
Convinced  that  dentine  7)iiist  be  supplied  with  sensitive  nerve 
fibres,  he  suggested  their  search  to  Professor  C.  Johnston,  whose 
microscopical  discoveries  demonstrated  the  fact  that  nerve  fila- 
ments constitute  an  essential  element  of  dentine. 

The  surface  of  the  dentine  of  the  crown  of  a  tooth,  is,  as 
stated  by  Professor  Owen,  marked  by  numerous  pits,  correspond- 
ing with  projections  of  the  enamel,  and  into  which  these  are 
received. 

Every  100  parts  of  dentine,  according  to  Berzelius,  contains. 
Phosphate  of  lime,         ....         62. 
Fluate  of  lime,      .....  2. 

Carbonate  of  lime,         ....  5.5 

Phosphate  of  magnesia,  ...  1. 

Soda  and  muriate  of  soda,      .  .  .  1,5 

Gelatin  and  water,         ....         28. 


100 
Von  Bibra  makes  dried  dentine  to  contain — 


ORGANS    OF    MASTICATION. 


51 


Phosphate  of  lime,  with  some 
fluoride  of  calcium, 

Molar  of  a 
woman  of  25. 

.     67.54 

Molar  of 
a  man. 

66.72 

Incisor  of  the 
.same  man. 

Carbonate  of  lime, 

.       7.9T 

3.36 

Phosphate  of  magnesia, 
Salts, 

.       2.49 
.       1-00 

1.08 

0.83 

Cartilage,      .... 

.     20.42 

27.61 

Fat, 

.       0.58 

0.40 

100.00 

100.00 

Organic  substance,     .         .         .     21.00         28.01         28.70 
Inorganic  substance,  .    .     .     79.00         71.99         71.30 

The  relative  proportions,  however,  of  organic  and  inorganic 

matter  are  not  always  the  same.     They  vary  according  to  the 

density  of  the  tooth. 

The  laminated  decomposition  which  occurs  in  caries   of  the 

teeth  is  owing  to  the  concentric  arrangement  of  the  dentine,  or, 

according  to  Mr.  Nasmyth,  of  the  cells. 


THE    ENAMEL. 

The  Enamel  {c  Fig.  9)  covers  the  crown,  and  extends  to  the 
neck  of  the  tooth,  but  terminating  more  remotely  from  the  gum 
upon  the  proximal,  than  upon  either  of  the  other  surfaces.  It  is 
the  hardest  of  all  animal  substances,  is  pearly  white,  or  slightly 
tinged  with  yellow,  according  to  the  texture  of  the  tooth.  Like 
the  dentine,  it  varies  in  density,  being  harder  in  some  teeth  than 
others.  It  is  thickest  on  those  parts  of  the  teeth  most  exposed 
to  friction,  as  on  the  eminences  of  the  molars  and  bicuspids,  and 
the  cutting  edges  of  the  incisors  and  points  of  the  cuspids,  gradu- 
ally diminishing  to  the  line  of  its  termination.  The  structure  of 
the  enamel,  according  to  Mr.  Nasmyth,  is  fihro-cellular — the 
fibres  radiating  from  the  dentine  to  the  surface  of  the  tooth — an 
arrangement  which  gives  to  this  outer  investment  immense 
strength  and  the  power  of  sustaining  great  pressure.  It  has 
a  smooth,  glossy  surface,  and  on  the  permanent  teeth,  is  charac- 
terized by  delicate  circular  ridges  and  furrows,  which,  as  stated 
by  Czermdk,  are  never  seen  on  the  temporary  teeth.  It  is  cover- 
ed by  a  delicate  calcified  membrane,  called,  by  Professor  Kolliker, 


52 


ORGANS    OF    MASTICATION. 


the  cuticle  of  the  enamel,  and  by  Huxley,  Nasmr/th's  membrane, 
because  Mr.  Nasmyth  was  the  discoverer  of  it.  He  terms  it  the 
'''•persistent  dental  capsule,''  and  says  it  is  continuous  with  the 
structure  covering  the  root.  This  membrane,  according  to  Pro- 
fessor Kolliker,  forms,  from  the  great  resistance  it  offers  to 
chemical  reagents,  a  peculiarly  appropriate  defence  for  the  crown 
of  the  tooth. 


Fu;. 


Fio.  24. 


Ftq.  23.  The  hexagonal  ter- 
minations of  the  fibres  of  a 
portion  of  the  surface  of  the 
enamel,  higlily  magnitied.  At 
1.  2,  ;(,  the  crooked  crevices, 
between  the  hexagonal  fibres, 
are  more  strongly  marked. 


Fig.  24.  A  side  view  of  the  euamel  fibres 
magnified  3.J0  diameters;  1  1,  The  enamel 
fibres ;  2  2,  Transverse  strije  upon  them. 

The  enamel  is  composed  of  prisms  or 
fibres,  for  the  most  part  of  an  hexagonal 
or  pentagonal  shape,  arranged  side  by 
side,  with  one  extremity  resting  upon  the 
dentine,  and  the  other  upon  Nasmytlis 
membrane,  which,  properly,  constitutes  the 
peripheral  surface  of  the  crown  of  the  tooth.  The  fibres  are 
marked,  as  seen  in  Fig.  24,  by  transverse  striae,  shoAving  them  to 
be,  as  is  remarked  by  Professor  Owen,  "  essentially  the  contents 
of  extremely  delicate  membranous  tubes,  originally  subdivided 
into  minute  depressed  compartments  or  cells,"  and  which,  the 
author  is  inclined  to  believe,  constitutes  the  animal  framework 
of  the  tissue,  and  probably  the  bond  of  union  between  the  fibres. 
The  existence,  however,  of  such  uniting  medium  is  not  univer- 
sally recognized  by  physiologists. 

The  prisms  of  the  enamel  have  a  wavy  course,  like  the  den- 
tinal fibres  of  the  crown  of  the  tooth,  the  curvatures,  for  the 
most  part,  being  parallel  to  each  other,  and  more  marked  near 
the  external  than  the  internal  surface.  The  curves,  however,  in 
the  enamel  fibres  are  shorter  and  more  strongly  marked  than  in 
the  dentinal  fibres.  The  prisms  usually  extend  through  the  entire 
thickness  of  the  enamel,  but  sometimes  they  fall  short,  and  at 
other  times  they  diverge  near  the  external  surface.  When 
either  of  these  happens,  ''shorter  complemental  fibres  fill  up  the 
interspace."     And  this  interpolation  of  enamel  prisms  in  the 


ORGANS    OF    MASTICATION, 


53 


outer  portion  of  their  substance  is  inevitable,  for  as  the  free 
surface  of  enamel  is  more  extensive  than  the  inner  or  dentinal 
surface,  and  as  the  prisms  are  everywhere  of  equal  diameter,  the 
prisms  springing  from  the  dentine  cups,  even  if  they  all  reached 
the  coronal  surface,  would  not  suffice  to  make  the  outer  layer 
complete. 

But  in  addition  to  the  pe-  ^'<^-  2!>- 

culiar  structural  arrange- 
ment just  described,  the 
enamel,  according  to  Mr. 
Nasmyth,  is  cellular.  Each 
cell  he  represents  (Fig.  25)  as 
having  a  semicircular  form, 
the  convexity  of  the  semi- 
circle looking  upwards  to- 
wards the  free  external  por- 
tion of  the  tooth.  This  ex- 
planation of  a  familiar  ap- 
pearance we  take   to  be   erroneous. 

Thus,  by  the  beautiful  and  peculiar  structural  arrangement  of 
the  enamel  prisms,  a  capability  of  resisting  mechanical  force  is 
given,  which  a  simply  fibrous  structure  would  be  wholly  inade- 
quate to  supply. 

The  enamel,  like  the  dentine,  consists  of  organic  and  inorganic 
matter — the  former  being  less  than  the  latter.  Its  chemical 
composition,  according  to  Berzelius,  is, 

Phosphate  of  lime,  .         .         .         85.3 


Fig.  25.  The  enamel  seea  in  a  section  not  quite 
at  right  angle.s  with  the  course  of  the  prLsms. 


Fluate  of  lime. 
Carbonate  of  lime. 
Phosphate  of  magnesia. 
Soda  and  muriate  of  soda. 
Animal  matter  and  water, 


3.2 
8.0 
1.5 
1.0 
1.0 


100 


54  ORGANS    OF    MASTICATION. 


Von  Bibra  makes  it  to  consist  of 

Phosphate  of   lime,  with 

From  a 
twenty 

some 

molar  of  a  woman 
-five  years  of  age. 

From  a  molar  of 
an  adult  man. 

fluoride  of  calcium, 

81.63 

89.82 

Carbonate  of  lime,  . 

8.88 

4.37 

Phosphate  of  Magnesia,  . 

2.55 

1.34 

Salts,      .... 

0.97 

0.88 

Cartilage, 

5.97 

3.39 

Fat,        .... 

a  trace 

0.20 

100.00 

100.00 

Organic  matters. 

5.97 

3.59 

Inorsranic  matters,  . 

, 

94-03 

96-41 

These  proportions,  as  in  the  case  of  dentine,  are  not  always 
the  same.  They  vary  in  the  enamel  of  the  teeth  of  Jiff'erent 
individuals. 

THE    CEMENTUM. 

The  Cementum,  or  Crusta  Petrosa,  {d,  Fig.  9,)  covers  the 
root,  commencing  where  the  enamel  terminates,  and  gradually 
increases  in  thickness  to  its  apex.  It  has  also  been  traced  over 
the  enamel,  and  Mr.  Nasmyth  is  of  the  opinion  that  it  always 
invests  the  crowns  of  the  teeth,  but  the  author  has  never  been 
able  to  detect  it  except  upon  the  roots.  If,  therefore,  it  is  formed 
ypon  the  crown,  it  is  evidently  soon  worn  off  by  the  friction  of 
mastication.  The  case  mentioned  by  Pm-kinjd  and  Frankel,  in 
which  they  discovered  it  upon  the  enamel  of  the  teeth  of  an  old 
man,  is  an  exception  to  the  general  rule. 

In  many  animals,  however,  it  covers  the  crowns  of  the  teeth, 
and  sometimes  unites  vertical  plates  of  enamel  and  dentine  into 
a  solid  tooth,  as  in  the  case  of  the  molar  teeth  of  the  elephant. 

Cementum  corresponds  in  structure  with  osseous  tissue,  being 
furnished  with  lacunfie,  and,  when  of  suflBcient  thickness,  is  tra- 
versed by  vessels  capable  of  conveying  red  blood.  Mr.  Tomes 
says  he  has  several  specimens  of  healthy  human  teeth,  in  the 
cementum  of  which  vascular  canals  exist ;  and  in  one,  where  two 
canals  enter  from  the  surface,  they  anastomose,  and  give  off  three 
branches. 

The  cementum,  like  dentine,  is  arranged  in  concentric  layers. 
It  is  also  cellular,  according  to  Mr.  Tomes,  the  cells  (lacunae)  being 


ORGANS    OF    MASTICATION.  55 

scattered  through  it  "with  some  degree  of  regularity,  generally, 
though  not  always,  following  a  course  as  though  placed  between 
concentric  laminae."  From  the  cells  tubes  are  given  off  which 
anastomose  with  each  other  and  with  those  from  contiguous  cells. 
"By  this  arrangement,"  says  the  author  last  named,  "a  net- 
work of  cells  and  tubes,  permeable  by  fluids,  is  carried  through 
the  whole  mass."  He  also  states  that  "  the  majority  of  the 
radiating  tubes  pass,  either  toward  the  surface  of  the  tooth,  or, 
when  such  exists,  toward  the  surface  of  a  canal  for  a  blood- 
vessel. Many  branches  also  go  toward  the  dentine,  and  anas- 
tomose with  the  terminal  branches  of  the  dentinal  tubes,  while 
a  few  follow  the  course  of  the  length  of  the  tooth,  anastomosing 
freely  with  tubes  pursuing  a  like  direction.  Frequently,  how- 
ever, a  cell  with  its  tubuli  resembles  a  tuft  of  moss,  the  mass 
of  tubes  taking  the  same  direction,  and  that  toward  a  surface 
upon  which  blood  vessels  pass."  The  cells  of  the  cement  are 
usually  oblong,  as  may  be  seen  in  Fig.  19,  though  sometimes 
they  are  circular  and  occasionally  fusiform.  They  are  as 
variable  in  size  as  in  shape.  The  average  of  their  long  diameter 
is  stated  by  Professor  Owen  to  be  about  ^g^o^h  of  an  inch. 

The  cementum  is  much  thicker  on  the  permanent  teeth  than  on 
the  temporary,  and  it  is  thicker  on  the  teeth  of  old  persons  than 
on  those  of  young.  In  the  former  case  it  is  often  reflected  into 
the  pulp  cavity  at  the  extremity  of  the  root,  sometimes  com- 
pletely obliterating  it  at  this  point. 

Cementum  is  composed,  according  to  Von  Bibra,  of 


la  man. 

In  the  ox. 

Organic  matters. 

29.42 

32.24 

Inorganic  matters, 

70.58 

67.76 

100.00 

100.00 

In  the  latter  he  found  : 

Phosphate  of  lime  and  fluoride  of  calcium, 

58.73 

Carbonate  of  lime. 

. 

7.22 

Phosphate  of  magnesia, 

0.99 

Salts, 

. 

0.82 

Cartilage,  . 

81.31 

Fat,  .... 

0.93 

100.00 


56 


ORGANS    OF    MASTICATION. 


Thus  it  is  seen,  that  the  cement  urn  contains  a  larger  propor- 
tion of  orficanic  matters  than  dentine,  and  it  ia  endowed 
with  greater  sensibility.  This  circumstance  will  account  for  the 
fact  that,  when  the  neck  of  a  tooth  becomes  exposed  by  the 
recession  of  the  gums,  the  slightest  touch  is  often  productive  of 
severe  pain.  The  cementum  is  necessary  to  the  preservation  of  the 
connection  between  the  teeth  and  the  general  system,  for  if  the 
dentine  of  the  roots  were  not  covered  by  it,  these  organs  would 
act  as  irritants,  and  nature  ■would  at  once  make  an  effort  to 
expel  them  from  the  body.  In  this,  therefore,  as  in  every  thing 
else  connected  with  the  animal  economy,  wisdom  of  design  is 
displayed. 

DESCRIPTIOX  OF  TEETH  BELONGING  TO  EACH  CLASS. 

Each  tooth,  as  has  already  been  remarked,  has  a  body  or 
crown,  a  neck,  and  a  root  or  fang.  In  describing  these  several 
parts,  I  shall  begin  with 


THE   INCISORS. 


The  Incisors  (four  to  each  jaw.  Fig.  26,  a  rt,  a  a,)  occupy  the 
anterior  central  part  of  each  maxillary  arch.     The  body  of  each 


Fig.  2G. 


d 


Pio.  26.    a  a,  a  a  Front  view  of  the  incisors  ;  b  b,  b  b  Palatine  or  lingaal  view ;  c  c,  c  c  Side 
or  lateral  view. 

is  wedge  shape — the  anterior  or  labial  surface  is  convex   and 


ORGANS   OF    MASTICATION.  57 

smooth ;  the  posterior  or  palatine  is  concave,  and  presents  a 
tubercle  near  the  neck;  the  })alatine  and  labial  surfaces  come 
together,  and  form  a  cutting  edge.  In  a  front  view,  the  edge  is, 
generally,  the  widest  part;  it  diminishes  toward  the  neck,  and 
continues  narrowing  to  the  extremity  of  the  root. 

The  crown  of  an  incisor  has  four  surfaces  ;  two  approximal,  one 
labial,  and  one  palatine  or  lingual — the  term  palatine  being  ap- 
plied to  an  upper,  and  lingual  to  a  lower  incisor.  It  also  has 
four  angles  ;  namely,  a  right  and  a  left  labio-apj^^oxinial,  and  a 
right  and  a  left  palato-approximal,  or  lingua-approximal. 

The  two  large  incisors  which  are  situated  one  on  each  side  of 
the  median  line,  are  termed  the  central ;  the  other  two,  the  lateral 
incisors,  or  laterals.  The  crowns  of  the  upper  central  incisors 
are  about  four  lines  in  breadth,  and  the  laterals  three.  In  the 
lower  jaw,  the  crowns  of  the  central  incisors  are  only  about  two 
lines  and  a  half  in  width,  while  the  laterals  are  usually  a  little 
wider.  But  the  width  of  the  crowns  of  all  the  incisors  varies  in 
different  individuals. 

The  length  of  a  superior  central  incisor  is  usually  about  one 
inch,  and  that  of  a  lateral  is  half  of  a  line  less.  In  the  lower 
jaw  the  central  incisors  are  only  about  ten  lines  in  length  ;  the 
laterals  are  about  one  line  and  a  half  longer. 

The  length  of  the  crown  of  an  incisor  is  exceedingly  variable. 
That  of  an  upper  central  varies  from  four  and  a  half  to  six  lines ; 
and  there  is  the  same  want  of  uniformity  in  this  respect  with  the 
crowns  of  all  the  incisors. 

The  roots  are  all  single,  of  a  conical  form,  flattened  laterally, 
and  slightly  furrowed  longitudinally.  The  enamel  is  thicker 
before  than  behind,  and  thinnest  at  the  sides. 

The  function  of  this  class  of  teeth,  as  their  name  imports,  is 
to  cut  the  food,  and  for  the  performance  of  this  office  they  are 
admirably  fitted  by  their  shape.  As  age  advances,  their  edges 
often  become  blunted  ;  but  the  rapidity  with  which  they  are  worn 
away,  depends  altogether  upon  the  manner  in  which  those  of  the 
upper  and  lower  jaw  come  together. 

THE    CUSPIDATI,   OR   CUSPIDS. 

The  Cuspidati,   Canini,   or  Cuspids   (Fig.   27),  are  situated 
next  to  the  incisors,  two  to  each  jaw,  one  on  either  side.     They 
5 


58 


ORGANS    OF    MASTICATION. 


Fig.  2i 


somewhat  resemble  the  upper  central  incisors  with  their  angles 
rounded.  Their  crowns  are  conical,  very  convex  externally  ; 
and  their  palatine  surface  more  uneven,  and  having  a  larger 
tubercle  than  the  incisors.  Their  ruots  are  also  larger,  and  of 
all  tlie  teeth  the  longest ;  like  the  incisors,  they  are  also  single, 
but  have  a  groove  extending  from  the 
neck  to  the  extremity,  showing  a  step 
towards  the  formation  of  two  roots.  A 
cuspid,  like  an  incisor,  has  four  surfaces, 
and  four  angles,  designated  by  the  names 
already  given. 

The  breadth  of  the  crown  of  an  up- 
per cuspid  is  about  four  lines,  that  of  a 
lower  is  about  three  and  a  half;  but  as 
in  the  case  of  the  incisors,  the  width  of 
the  crowns  of  these  teeth  is  variable. 
The  length  of  a  cuspid  is  greater  than 
that  of  any  other  tooth  in  the  den- 
tal series — it  being  about  thirteen  lines. 
The  breadth  of  the  neck  of  one  of  these 
teeth  is  about  one-third  greater  in  front 
than  behind,  and  from  before  backwards 
it  measures  about  four  lines. 

The  upper  cuspids  are  called  eye-teeth  ; 
the  lower  are  termed  stomach  teeth. 
These  teeth  are  for  tearing  the  food,  and  in  some  of  the 
carnivorous  animals,  where  they  are  very  large,  they  not  only 
rend  but  also  hold  their  prey. 

The  incisors  and  cuspids  together  are  termed  the  oral  teeth. 


Fio.  27.  a  a  Front  view 
of  the  cuspids  ;  b  b  Palatine 
and  lingual  view  ;  c  c  Side 
view. 


THE    BICUSPIDS. 


The  Bicuspids,  (Fig.  28,)  four  to  each  jaw,  and  two  on  either 
side,  are  next  in  order  to  the  cuspids.  They  are  so  called 
from  their  having  two  distinct  prominences  or  cusps  on  their 
grinding  surfaces.  They  are  also  named  the  small  molars.  They 
are  thicker  from  their  buccal  to  their  palatine  surface  than  either 
of  the  incisors,  and  are  flatter  on  their  sides.  The  grinding  sur- 
face of  each  is  surmounted  by  two  conical  tubercles,  separated  by 
a  groove  running  in  the  direction  of  the  alveolar  arch;  the  outer 


ORGANS    OF    MASTICATION. 


59 


is  larger  and  more  prominent  than  the  inner.  In  the  lower  jaw 
these  tubercles  are  smaller  than  in  the  upper,  and  the  inner  is 
sometimes  wholly  wanting. 

A    bicuspid    has    five  '^'  ^^' 

surfaces ;  namely,  two 
approximalj  one  anterior 
and  one  posterior;  one 
buccal;  one  ixdatine  or 
lingual  surface,  as  the 
tooth  may  be  in  the  upper 
or  lower  jaAv,  and  one 
grinding  surface.  It  has 
also  four  angles  ;  one  an- 
terior, and  one  posterior 
2)aIato-ap2)roximaI,  and 
one  anterior  and  one  pos- 
terior hucco-approximal 
angle. 

The  size  of  these  teeth,  like  that  of  the  incisors  and  cuspids, 
is  variable.  The  buccal  surface  of  the  crown  of  a  superior 
biscuspid  of  ordinary  size  at  its  broadest  part,  is  about  three 
lines  in  breadth,  while  the  anterior  and  posterior  approximal 
surfaces  are  about  four  lines.  The  palatine  is  not  quite  as  wide 
as  the  buccal  surface.  All  the  diameters  of  the  crown  of  a 
lower  bicuspid  are  usually  a  little  less  than  those  of  an  upper. 
The  entire  length  of  a  bicuspid  is  ordinarily  about  eleven  lines. 

The  roots  of  the  bicuspids  are,  generally,  simple ;  though  the 
groove  is  deeper  than  in  the  cuspids,  and  not  unfrequently  ter- 
minates in  two  roots,  which  have  each  an  opening  for  the  vessels 
and  nerves  to  enter.  The  inner  root,  however,  is  always  smaller 
than  the  outer.  Two  fanged  bicuspids  are  more  frequently  met 
with  in  negroes  than  in  whites  ;  and  the  double  fang  is  common, 
if  not  constant,  in  the  aboriginal  Australians. 


Fia.  28.  a  a,  a  a  Buccal  view  of  the  bicuspids  ;  b  b,b  b 
Palatine  and  lingual  view  ;  c  c,  c  c  Side  view. 


60 


ORGANS    OF    MASTICATION. 


THE    MOLARS. 

The  Molars  (Fig.  29)  occupy  the  posterior  part  of  the  alveolar 

Fig.  29. 


arch,  and  are  six  in  each  jaw, 
three  on  either  side.  They  are 
distinguished  by  their  greater 
size,  the  first  and  second  being 
the  largest ;  the  grinding  sur- 
faces have  the  enamel  thicker, 
and  are  surmounted  by  four  or 
five  tubercles  or  cusps,  with  as 
many  corresponding  depressions, 
arranged  in  such  a  manner  that 
the  tubercles  of  the  upper  jaw 
are  adapted  to  the  depressions 

A 

molar,  like  a  bicuspid,  has  also 
five  surfaces  and  five  angles,  designated  by  the  names  already 
given. 

The  upper  molars  have  three  roots,  sometimes  four,  and  as 
many  as  five  are  occasionally  seen  ;  of  these  roots  two  are  situ- 
ated externally,  almost  parallel  with  each  other,  and  perpendicu- 
lar ;  the  tliird  root  forms  an  acute  angle,  and  looks  toward  the 
roof  of  the  mouth.  The  former  are  called  the  buccal  roots,  and 
the  latter  the  palatine.  The  roots  of  the  two  first  superior  mo- 
lars correspond  with  the  floor  of  the  maxillary  sinus,  and  some- 


i  i'..  .;•    II  a  II,  a  a  a  Outer  view  of  the  mo-        e  j.-\       ^  i      • 

Inrs;  6  6  6,  6  6  6  Inner  view;  c  c  c,  c  c  c  Side     01  the  lOWCr,   and  VlCC  VCrsa 


ORGANS    OF    MASTICATION.  61 

times  protrude  into  this  cavity,  their  divergence  securing  them 
more  firmly  in  their  sockets.  The  lower  molars  have  but  two 
roots,  the  one  anterior,  the  other  posterior  ;  they  are  nearly  verti- 
cal, parallel  with  each  other  and  much  flattened  laterally. 

The  last  molar,  called  the  dens  sapientice,  or  wisdom  tooth,  is 
both  shorter  and  smaller  than  the  others,  the  roots  of  the  upper 
wisdom  tooth  are,  occasionally,  united  so  as  to  form  but  one  ; 
while  the  last  molar  of  the  lower  jaw  is  generally  single  and  of  a 
conical  form. 

The  roots  of  the  molar  teeth,  both  of  the  upper  and  lower  jaw, 
after  diverging,  sometimes  approach  each  other,  embracing  the 
intervening  bony  partition  in  such  a  manner  as  to  constitute  an 
obstacle  to  their  extraction. 

The  bucco-palatine  diameter  of  the  crown  of  an  upper  molar 
is  usually  a  little  less  than  the  antero-posterior.  In  the  lower 
jaw,  the  bucco-lingual  and  antero-posterior  diameters  are  gene- 
rally about  the  same. 

The  crown  of  the  first  molar  is  generally  larger  than  the 
second,  and  the  second  larger  than  the  third  or  wisdom  tooth  ; 
and  the  crown  of  the  last  named  tooth  is  always  smaller  in  the 
upper  than  in  the  lower  jaw. 

The  length  of  a  molar  tooth  varies  from  eight  to  twelve  and  a 
half  or  thirteen  lines. 

The  molars  and  bicuspids  together  constitute  what  are  termed 
the  buccal  teeth. 

The  use  of  the  molars,  as  their  name  signifies,  is  to  triturate 
or  grind  the  food  during  mastication,  and  for  this  purpose  they 
are  admirably  adapted  by  their  mechanical  arrangement. 

ARTICULATION  OF  THE  TEETH. 

The  manner  in  which  the  teeth  are  confined  in  their  sockets, 
is  by  a  union  called  gomphosis,  from  the  resemblance  of  this  kind 
of  articulation  to  the  way  in  which  a  nail  is  received  into  a 
board.  Those  teeth  having  but  one  root,  and  those  with  two 
perpendicular  roots  depend  greatly  for  the  strength  of  their 
articulation  on  their  nice  adaptation  to  their  sockets. 

Those  having  three  or  four  roots  have  their  firmness  much  in- 
creased by  their  divergence. 


62 


ORGANS   OF    MASTICATION. 


Fig.  30. 


But  there  are  other  bonds  of  union ;  by  the  periosteum  lining 

the  alveolar  cavities,  and 
investing  the  roots  of  the 
teeth ;  also  by  the  blood 
vessels  entering  the  apices 
of  the  roots  ;  and  finally, 
by  the  gums,  which  will 
be  noticed  in  another  place. 


DIFFERENCES  BETWEEN 
THE  TEMPORARY  AND 
PERMANENT  TEETH. 

The  temporary  and  per- 
manent teeth  differ  in 
several  respocti^,  and  on  this  point  I  will  give  Mr.  Bell's  obser- 
vations : 

"  The  temporary  teeth  are,  generally  speaking,  much  smaller 
than  the  permanent ;  of  a  less  firm  and  solid  texture,  and  their 
characteristic  forms  and  prominences  much  less  strongly  marked. 
The  incisors  and  cuspids  of  the  lower  jaw  are  of  the  same  general 
form  as  in  the  adult,  though  much  smaller ;  the  edges  are  more 
rounded,  and  they  are  not  much  more  than  half  the  length  of 
the  latter.  The  molars  of  the  child,  on  the  contrary,  are  con- 
siderably larger  than  the  bicuspids  which  succeed  them,  and  re- 
semble very  nearly  the  permanent  molars. 

"  The  roots  of  the  tooth,  in  the  molars  of  the  child,  are  similar 
in  number  to  those  of  the  adult  molars,  but  they  are  flatter  and 
thinner  in  proportion,  more  hollowed  on  their  inner  surfaces,  and 
diverge  from  the  neck  at  a  more  abrupt  angle,  forming  a  sort  of 
arch." 


RELATIONS  OF  THE  TEETH  OF  THE  UPPER  TO  THOSE  OF  THE 
LOWER  JAW,  WHEN  THE  MOUTH  IS  CLOSED. 

The  crowns  of  the  teeth  of  the  upper  jaw  generally  describe 
a  rather  larger  arch  than  those  of  the  lower.  The  upper'in- 
oisors  and  cuspids  usually  shut  over  and  in  front  of  the  lower ; 
but  sometimes  they  fall  plumb  upon  them,  and  at  other  times, 
though  rarely,  they  come  on  the  inside.     The  external  tubercles 


ORGANS    OF    MASTIC'aTION.  63 

or  cusps  of  the  superior  bicuspids  and  molars,  generally  strike 
on  the  outside  of  those  of  the  corresponding  inferior  teeth.  By 
this  beautiful  adaptation  of  the  tubercles  of  the  teeth  of  one  jaw 
to  the  depressions  of  those  of  the  other,  every  part  of  the  grind- 
ing surface  of  these  organs  is  brought  into  immediate  contact  in 
the  act  of  mastication ;  Avhich  operation  of  the  teeth,  in  conse- 
quence, is  rendered  more  perfect  than  it  would  be  if  the  organs 
came  together  in  any  other  manner. 

The  incisors  and  cuspids  of  the  upper  jaw  are  broader  than 
the  corresponding  teeth  in  the  lower ;  in  consequence  of  this  dif- 
ference in  the  lateral  diameter  of  the  teeth  of  the  two  jaws,  the 
central  incisors  of  the  upper  cover  the  centrals  and  about  half  of 
the  laterals  in  the  lower,  while  the  superior  laterals  cover  the 
remaining  half  of  the  inferior  and  the  anterior  half  of  the  adjoin- 
ing cuspids.  Continuing  this  peculiar  relationship,  the  upper 
cuspids  close  over  the  remaining  half  of  the  lower  and  the  an- 
terior half  of  the  first  inferior  bicuspids,  while  the  first  superior 
bicuspids  cover  the  remaining  half  of  the  first  inferior  and  the 
anterior  half  of  the  second.  In  like  manner,  the  second  bicus- 
pids of  the  upper  jaAV  close  over  the  posterior  half  of  the  second 
and  the  anterior  third  of  the  first  molars  in  the  lower.  The  first 
superior  molars  cover  the  remaining  two-thirds  of  the  first  in- 
ferior and  the  anterior  third  of  the  second ;  while  the  two-thirds 
of  this  last  and  anterior  third  of  the  lower  dentes  sapientiae,  are 
covered  by  the  second  upper  molars.  The  dentes  sapientiae  of 
the  superior  maxilla,  being  usually  about  one-third  less  in  their 
antero-posterior  diameter,  cover  the  remaining  two-thirds  of  the 
corresponding  teeth  in  the  lower  jaw.     (See  Fig.  30.) 

Thus,  from  this  arrangement  of  the  teeth,  it  will  be  seen,  that 
when  the  mouth  is  closed,  each  tooth  is  opposed  to  two ;  and 
hence,  in  biting  hard  substances,  and  in  mastication,  by  extend- 
ing this  mutual  aid,  a  power  of  resistance  is  given  to  these  organs 
which  they  would  not  otherwise  possess.  Moreover,  as  a  late 
English  writer,  Mr.  Tomes,  very  justly  observes,  if  one,  or  even 
two  adjoining  teeth  should  be  lost,  the  corresponding  teeth  in 
the  other  jaw  would,  to  some  extent,  still  act  against  the  con- 
tiguous organs ;  and  thus,  in  some  degree,  counteract  a  process, 
first  noticed  by  that  eminent  dentist.  Dr.  L.  Koecker,  which 
nature  sometimes  sets  up  for  the  expulsion  of  such  teeth  as  have 
lost  their  antagonists. 


64 


ORGANS    OF    MASTICATIOX, 


The  order  and  time  in  wliich  both  temporary  and  permanent 
teeth  appear,  will  be  noticed  in  the  chapters  on  First  and  Second 
Dentition. 


ACTIVE  ORGANS  OF  MASTICATION. 

The  active  organs  of  mastication  consist  of  the  muscles  at- 
tached, principally,  to  the  upper  and  lower  maxillary  bones,  the 
temporals,  malar  bones  and  the  sphenoid  :  by  these,  the  various 
motions  of  mastication  are  effected. 

They  are  the  temporalis,  the  masseter,  pterygoideus  externus, 
and  the  pterygoideus  internus. 

The    Temporal  3Iu8cle  (Fig.  31)  is  seen   on  the  side  of  the 

Fig.  31. 


Pirt.  3\.  fi  .Side  view  of  the  temporal  muscle,  expu.-.tU  Ijy  the  removal  of  the  tempoTal  fascia  ' 
6  External  lateral  ligament  of  the  lower  jaw  ;  c  Insertion  of  temporal  mnscle  into  coronoid  process 
of  lower  jaw. 

head  ;  it  has  its  origin  from  the  semicircular  ridge  commencing 
at  the  external  angular  process  of  the  os-frontis,  and  extending 
along  this  and  the  parietal  bones — also  from  the  surfaces  below 
this  ridge  formed  l)y  the  frontal  and  squamous  portion  of  the 
temporal  and  sphenoid  bones ;  likewise  from  the  under  surface 
of  the  temporal  aponeurosis,  a  strong  fascia  covering  this  muscle  ; 
and  its  fibres  are  inserted,  after  they  have  converged  and  passed 
under  the  zygoma,  into  the  coronoid  process  of  the  lower  jaw, 
surrounding  it  on  every  side  by  a  dense  strong  tendon. 


ORGANS    OF    MASTICATION. 


65 


The  office  of  this  muscle  is  to  bring  the  two  jaws  together,  as 
in  the  cutting  and  rending  of  the  food. 

The  Masseter  Muscle  (Fig.  32)  is   seen   at   the  side  and  back 


Fig. 


Fro.  32.  Side  view  of  the  muscles  of  external  ear,  cranium  and  face  :  a  Occipito-froutalis  ;  6 
Orbicularis  palpebrarum;  c  Pyramidalis  nasi;  d  Compressor  nasi;  e  and/Levator  labii  supe- 
rioris  alseque  nasi;  g  Zygomaticus  minor:  ftZygomaticas  major;  i  Masseter  Muscle; ./  Buccinator 
muscle;  /i  Depressor  anguli  oris;  /  Depressur  labii  iuferioris ;  m  Orbicularis  oris;  n  Anterior 
auris  ;  o  Superior  auris ;  p  Posterior  auris  ;  q  External  lateral  ligament ;  r  Deep-seated  portion  of 
masseter  muscle  ;  s  Temporal  fascia. 

part  of  the  face  in  front  of  the  meatus  externus,  and  lies  directly 
under  the  skin.  It  arises  by  two  portions :  the  one  anterior 
and  tendinous,  from  the  superior  maxilla  where  it  joins  the 
malar  bone ;  the  other  portion,  mostly  fleshy,  from  the  inferior 
edge  of  the  malar  bone  and  the  zygomatic  arch  as  far  back  as 
the  glenoid  cavity  ;  and  is  inserted,  tendinous  and  fleshy,  into 
the  external  side  of  the  ramus  of  the  jaw  and  its  angle  as  far  up 
as  the  coronoid  process. 

The  use  of  this  muscle,  when  both  portions  act  together,  is  to 
close  the  jaws;  if  the  anterior  acts  alone,  the  jaw  is  brought 
forward,  if  the  posterior,  it  is  drawn  backward. 

Pterygoideus  Externus  (a  and  b  Fig.  33)  arises  from  the 
outer  surface  of  the  external  plate  of  the  pterygoid  process  of 
the  sphenoid  bone,  from  the  tuberosity  of  the  superior  maxilla, 
and  from  the  ridge  on  the  sphenoid  bone  separating  the  zygo- 
matic from  the  pterygoid  fossa ;  and  is  inserted  into  the  inner 
side  of  the  neck  of  the  lower  jaw,  and  capsular  ligament  of  the 
articulation. 


66 


ORGANS    OF    MASTICATION. 


Pterygoideus  Internus  arises,  tendinous  and  fleshy,  from  the 
inner  surface  of  the  pterygoid  plate,  fills  up  the  greater  part  of 
the  pterygoid  fossa,  and  is  inserted,  tendinous  and  fleshy,  into 


Fig.  33. 


Fig.  33.   a  and  b  Superior  and  inferior  portions  of  the  pterygoideus  externus;   c  Pterygoideus 
internus  :  d  Root  of  zygomatic  process;  e  Condyle. 

The  ramus  is  cut  away  to  show  the  internal  pterygoid  muscle. 

the  inner  face  of  the  angle  of  the  inferior  maxilla  and  the  rou'rh 
surface  above  the  angle. 

These  tAVO  muscles  are  the  great  agents  in  producing  the 
grinding  motion  of  the  jaws,  and  this  they  do  by  acting  alter- 
nately. 

The  external  one  is  triangular,  having  its  base  at  the  ptery- 
goid process  aud  running  outwards  and  backwards  to  the  neck 
of  the  condyle.  When  the  pair  act  together,  the  lower  jaw  is 
thrown  forward.s.  The  internal  is  strong  and  thick,  placed  on 
the  inside  of  the  ramus  of  the  jaw,  and  running  downwards  and 
4>ackwards  to  the  angle.  When  the  pair  act  together,  the  jaw 
is  drawn  forward  and  closed. 


CHAPTER    THIRD. 
ORGANS  OF  INSALIVATION. 

The  Organs  of  InsaJivation  are  the  salivary  glands,  six  in 
number,  three  on  each  side  of  the  face,  named  the  Parotid, 
Submaxillary  and  Sublingual. 


These  glands  are  the  prime  organs  in  furnishing  the  salivary 
fluids  to  the  mouth  during  the  process  of  mastication. 


Fig.  34. 


Fio.  34.  View  of  the  salivary  glands;  a  Parotid  gland  ;  b  Submaxillary  gland  ;  c  Sublingual 
glands  ;  d  Duct  of  Steno  ;  e  Duct  of  Wharton,  or  submaxillary  duct. 

The  Parotid  Gland,  {a  Fig.  34,)  so  called  from  its  situation 
near  the  ear,  is  the  largest  of  the  salivary  glands.  Its  form  is 
very  irregular ;  it  fills  the  space  lying  between  the  ramus  of  the 
inferior  maxilla  and  mastoid  process  of  the  temporal  bone,  as 
far  back  as,  and  even  behind,  the  styloid  process  of  the  same 
bone.  Its  extent  of  surface  is  from  the  zygoma  above  to  the 
angle  of  the  lower  jaw  below,  and  from  the  mastoid  process  and 
meatus  externus  behind  to  the  masscter  muscle  in  front,  over- 
lapping its  posterior  portion. 

This  gland  is  one  of  the  conglomerate  order,  and  consists  of 


68 


ORGANS    OF    INSALIVATIOX. 


numerous  small  granular  bodies  connected  together  by  cellular 
tissue ;  each  of  Avhich  may  be  considered  a  small  gland  in  minia- 
ture, as  each  is  supplied  with  an  artery,  vein  and  secretory 
duct. 

The  gland  thus  formed,  presents  on  its  external  surface  a  pale, 
flat,  and  somewhat  convex  appearance. 

It  is  covered  by  a  dense,  strong  fascia  extending  from  the 
neck,  and  attached  to  the  meatus  externus  of  the  ear ;  it  sends 
countless  processes  into  every  part  of  the  gland,  separating  its 
lobules  and  conducting  the  vessels  through  its  substance. 

The  use  of  this  gland  is  to  secrete  or  separate  from  the  blood 
the  greater  part  of  the  saliva  furnished  to  the  mouth.  As  the 
parotid  is,  however,  on  the  outside,  and  at  some  little  distance 
from  the  mouth,  it  is  furnished  with  a  duct  to  convey  its  fluid 
into  this  cavity;  this  duct  is  called  the  duct  of  Steno,  or  the 
parotid  duct.  It  is  formed  of  the  excretory  ducts  of  all  the 
granules  composing  this  gland,  which,  successively  uniting  to- 
gether, at  last  form  one  common  duct. 

The  duct  of  Steno  commences  at  the  anterior  part  of  the 
gland  and  passes  over  the  masseter  muscle,  on  a  line  drawn 
from  the  lobe  of  the  ear  to  the  middle  part  of  the  upper  lip ; 
then  passes  through  a  quantity  of  soft  adipose  matter,  and 
finally,  enters  the  mouth  by  passing  through  the  buccinator 
muscle  and  mucous  membrane  opposite  the  second  molar  of  the 
upper  jaw. 

It  is  a  fact  established  by  experiment,  that  the  two  parotid 
glands  do  not  usually  pour  out  their  secretion  simultaneously, 
but  that  gland  alone  furnishes  its  fluid,  which  is  on  the  side  on 
which  the  bolus  of  food  is  being  ground  by  the  molars. 


The  Submaxillary  [b  Fig.  34)  is  the  next  in  size  of  the  sali- 
vary glands.  It  is  situated  under  and  along  the  inferior  edge 
of  the  body  of  the  lower  jaw,  and  is  separated  from  the  parotid 
simply  by  a  process  of  fascia. 

It  is  of  oval  form,  pale  color,  and,  like  the  parotid,  consists 
in  its  structure  of  small  granulations,  held  together  by  cellular 
tissue ;  and  each  having  a  small  excretory  duct,  which,  succes- 
sively uniting  with  one  another,  finally  form  one  common  duct. 
This,  the  duct  of  Wharton,  passes  above  the  mylo-hyoid  muscle. 


ORGANS    OF    INSALIVATION. 


69 


and  running  forward  and  inward  enters  the  mouth  below  the 
tip  of  the  tongue  at  a  papilla  seen  on  either  side  of  the  fraenum 
lingujB. 

The  use  of  this  gland  is  the  same  as  the  parotid,  to  secrete  a 
fluid  constituent  of  the  saliva,  and  its  duct  is  the  route  by  which 
it  is  conducted  into  the  mouth. 


The  Sublingual  Glands  [e  Fig.  34)  are  the  last  in  order  of  the 
salivary  glands,  and  the  smallest  in  size. 

They  are  situated  beneath  the  anterior  and  lateral  parts  of  the 
tongue,  are  covered  by  the  mucous  membrane,  and  rest  upon 
the  mylo-hyoid  muscle. 

They,  like  the  two  glands  just-described,  consist  of  a  granular 
structure  with  excretory  ducts  ;  which,  however,  do  not  unite  into 
one  common  duct,  but  enter  the  cavity  of  the  mouth  by  many 
ducts,  whose  openings  are  through  the  mucous  membrane  be- 
tween the  tongue  and  the  inferior  cuspid  and  bicuspid  teeth. 

Their  office  is  the  same  as  the  parotid  and  submaxillary. 


Fio.  35    A  view  of  inner  side  of  tiie  lips,  with  the  raucous  membrane  removed  so  as  to  show 
the  labial  and  buccal  glands;  a  a  Ducts  of  Steno;  b  b  Labial  glands. 

The  Mucous  Cflands,  (Fig.  35.)  Besides  the  glands  furnish- 
ing the  saliva,  there  is  another  series  of  much  smaller  size,  called 
the  mucous  glands.  They  are  simply  the  little  crypts,  follicles, 
or  depressions  everywhere  found  in  the  mucous  membrane  of  the 
mouth,  and  named,  according  to  their  situation,  the  glandulse 
labiales,  glanduloe  buccales,  etc.  The  lips,  cheeks  and  palate 
are  also  furnished  with  glands,  about  the  size  of  a  small  pea, 
which  present  the  true  salivary  structure. 

The  use  of  these  glands  is  to  furnish  the  mucus  of  the  mouth, 
which  they  pour  into  this  cavity  by  single  orifices,  opening  every 
where  on  its  surface. 


CHAPTER   FOURTH. 
ORGAxVS  OF  DEGLUTITIOX. 

The  Organs  of  Deglutition  succeed  next  in  the  physiological 
order,  and  are  the  last  in  the  series  belonging  to  the  mouth  as 
concerned  in  the  primary  stages  of  digestion. 

They  consist  of, 

1.  The  Pharynx, 

2.  The  Soft  Palate,  and 

3.  The  Tongue. 

This  class  of  organs,  as  the  term  implies,  is  concerned  in 
swallowing,  or  conveying  the  food,  after  it  has  undergone  the 
process  of  mastication,  and  become  properly  mixed  with  the 
salivary  fluids,  into  the  esophagus,  to  be  thence  conducted  into 
the  stomach  for  the  after  stages  of  digestion. 

The  Pharynx  (Fig.  36)  is  a  large  musculo-membranous  bag, 
open  in  front,  and  situated  behind  the  mouth,  the  nares,  and  soft 
palate.  It  is  connected  above  by  a  strong  aponeurosis  to  the 
basilar  process  of  the  occipital  bone,  and  extends  below  as  far  as 
the  fourth  and  fifth  cervical  vertebrne  ;  behind,  it  is  attached  to 
the  bodies  of  the  vertebrie,  and,  laterally,  it  is  connected  with 
the  expanded  cornua  of  the  hyoid  bone. 

By  these  several  attachments,  it  forms  a  constant  and  unoccu- 
pied cavity,  in  which  may  be  seen  seven  openings  leading  from 
it,  in  various  directions.  The  two  posterior  nares  are  at  the 
upper  and  nasal  portion ;  on  each  side  of  these,  and  at  the  back 
part  of  the  inferior  spongy  bones  are  the  two  Eustachian  tubes 
leading  to  the  ear.  In  front  and  below  the  velum,  is  the 
opening  into  the  mouth,  and  still  lower  down  the  opening  of  the 
glottis  and  the  commencement  of  the  oesophagus. 

The  Muscles  of  the  Pliarynx  are  four  in  number,  namely  : 

1.  The  Superior — constrictor  pharyngis  superior. 


OKGANS    OF    DEGLUTITION. 


71 


2.  The  Middle — constrictor  pharyngis  medius. 

3.  The  Inferior — constrictor  pharyngis  inferior. 

4.  Stylo  pharyngeus. 

The  constrictors  are  seen  on  the  posterior  part  of  the  pharynx 
after  removing  the  cervical  vertebrre,  and  present  very  much  the 
appearance  of  one  continued  sheet  of  muscle. 


Fig.  36. 


Fig.  37. 


Fro.  36.  Po.steiior  view  of  the  muscles  of  the  pharynx.  1,  vertical  section,  transversely  of  the 
base  of  the  skull,  just  in  advance  of  the  cervical  vertebra  ;  2.  3,  posterior  border  and  angle  of  the 
lower  jaw  :  4,  internal  pterygoid  innscle ;  .5,  styloid  process  giving  attachment  to  6,  the  stylo- 
pharyngeal muscle ;  7,  larynx  ;  8,  inferior  constrictor  of  the  pharynx  ;  9,  middle  constri^ctor  ;  10, 
superior  constrictor. 

Fid.  37.  Side  view  of  the  muscles  of  the  pharynx.  1,  trachea;  2,  cricoid  cartilage;  3,  vocal 
membrane  :  6,  hyoid  bone  ;  7,  stylo-hyoid  ligament ;  8.  oesophagus  ;  9,  inferior  constrictor  of  the 
pharynx;  10,  middle  constrictor;  11,  superior  constrictor;  12,  portion  of  the  stylopharyngeal 
muscle  observed  passing  into  the  interval  between  the  superior  and  middle  constrictors  ;  13,  upper 
extremity  of  the  pharynx;  14,  ptervgo-maxillary  ligament;  1.5,  buccinator  muscle;  16,  oral 
orbicular  muscle  ;  17,  mylo-hyoid  muscle. 

The  Superior  Constrictor  (10  Fig.  36)  arises  from  the  cunei- 
form process  of  the  occipital  bone,  from  the  lower  part  of  the  inter- 
nal pterygoid  plate  of  the  sphenoid  bone,  from  the  pterygo- 
maxillary  ligament,  and  from  the  posterior  third  of  the  mylo-hyoid 
ridge  of  the  lower  jaw,  near  the  root  of  the  last  molar  tooth.  It 
is  inserted  with  its  fellow  into  the  middle  tendinous  line  at  the 
back  of  tbe  pharynx. 


The  Middle  Constrictor  of  the  pharynx  (9  Fig.  36)  arises 
from  the  appendix  and  both  cornua  of  the  os-hyoides,  and  from 
the  thyro-hyoid  ligament ;  its  fibres  ascend,  run  transversely  and 
descend,  giving  a  triangular  appearance  ;  the  upper  ones  overlap 
the  superior  constrictor,  while  the  lower  are  beneath  the  inferior  ; 


72 


ORGANS    OF    DEGLrXITION. 


the  whole  pass  back  to  be  inserted  into  the  middle  tendinoii>i 
line  of  the  pharynx. 

The  Inferior  Constrictor  of  the  pharynx  (8  Fig.  36)  arises 
from  the  side  of  the  thyroid  cartilage  and  its  inferior  cornu,  and 
from  the  side  of  the  cricoid  cartilage,  and  is  inserted  with  its 
fellow  into  the  middle  line  on  the  back  of  the  pharynx. 

This  is  the  largest  of  the  constrictor  muscles,  and  overlaps  the 
middle  constrictor. 

The  action  of  all  these  muscles  is,  to  compel  the  food  to  take 
the  doAvnward  direction  into  the  oesophagus.  The  pharynx  is 
lined  Avith  mucous  membrane. 

The  Stylo  Pharyngeus  arises  from  the  root  of  the  styloid  pro- 
cess, and  is  inserted  into  the  side  of  the  pharynx  and  corner  of 
the  os-hyoides  and  thyroid  cartilage.  It  is  a  long  and  narrow 
muscle,  and  passes  to  the  pharynx  betAveen  the  upper  and  middle 
constrictors.  Its  use  is  to  elevate  and  draw  forward  the  pharynx, 
to  receive  the  food  from  the  mouth,  also  to  raise  the  larynx. 


THE  SOFT  PALATE. 

The  Soft  Palate  is  a  movable  curtain,  composed  of  mucous 
membrane,  enclosing  several  muscles.  It  is  situated  at  the  back 
part  of  the  mouth  between  this  cavity  and  the  pharynx,  is  con- 
nected above  to  the  posterior  edge  of  the  hard  palate,  and 
laterally  to  the  side  of  the  tongue  and  pharynx. 

By  this  arrangement,  the  soft  palate  has  the  appearance  of  a 
lunated  or  arched  veil  between  the  cavity  of  the  mouth  and  the 
pharynx. 

In  the  centre  of  this  arch  an  oblong  body  is  suspended,  called 
the  uvula,  which  divides  the  soft  palate  into  lateral  half  arches, 
that  pass  on  either  side  from  the  uvula  to  the  root  of  the  tongue. 

There  is  also  seen  passing  from  the  uvula  on  each  side  to  the 
pharynx,  two  other  arches,  which,  from  being  behind  the  first, 
are  called  the  posterior  arches,  or  pillars. 

Between  the  anterior  and  posterior  pillars,  on  either  side,  is  a 
triangular  interval  containing  the  tonsil  glands. 

Hhe  fauces  are  the  straits  or  passage  leading  from  the  mouth 


ORGANS    OF    DEGLUTITION. 


73 


to  the  pharynx ;  and  the  space  included  between  the  soft  palate 
above,  the  half  arches  and  tonsils  on  either  side,  and  the  root  of 
the  tongue  below,  is  called  the  isthmus  of  the  fauces. 

The  muscles  of  the  palate  are  four  pairs,  and  one  single  one, 
namely : 

1.  The  Levator  Palati. 

2.  The  Tensor  or  Circumflexus  Palati. 

3.  Constrictor  Isthmi-Faucium,  or  Palato-Glossus. 

4.  Palato-Pharyngeus. 

5.  Azygos-Uvulae  is  the  single  muscle. 


Fig.  38. 


The  Levator  Palati  (b  b  Fig. 
38)  arises  from  the  point  of  the 
petrous  portion  of  the  temporal 
bone  and  adjoining  portion  of 
the  Eustachian  tube,  descends 
and  is  inserted  into  the  soft 
palate.  Its  use  is  to  raise  the 
palate. 


The    Tensor,  or    Circumflexus      Fm.  38.  Posterior  view  of  the  muscle  of  the 

soft  palate:  a  Roof  of  the  moutli  or  hard  palate  ; 

Palati.    arises    from    the    base    of ''&  Levator  palatl ;  c  Ba.sllar  portion  of  sphenoid 

'  bone;  d  d   Eustachian  tubes;   e  Tensor  or  clr- 

the     pterygoid     process     of      the  cumaexus  paIati;/Azygos-uvula;;  ffSfPalato- 

t^        t/  o  r  pharyngeus — posterior  halt  arch. 

sphenoid    bone,    and    from    the 

Eustachian  tube,  descends  in  contact  with  the  internal  pterygoid 
muscle  to  the  hamulus,  round  which  it  winds,  and  is  inserted  into 
the  soft  palate  where  it  expands  and  joins  its  fellow.  Its  office 
is  to  spread  the  palate. 

Constrictor  Isthmi-Faucium  occupies  the  anterior  lateral  half 
arches  of  the  palate ;  it  arises  from  the  side  of  the  tongue  near 
its  root,  and  is  inserted  into  the  velum  near  the  uvula. 

It  draws  the  velum  down  and  closes  the  opening  of  the  fauces. 


Palato-Pharyngeus  occupies  the  posterior  lateral  half  arches 
of  the  palate,  and  extends  from  the  soft  palate  behind,  near  the 
uvula,  as  its  origin,  and  is  inserted  into  the  pharynx  between 
the  middle  and  lower  constrictors  and  into  the  thyroid  cartilage. 

Its  use  is  to  draw  down  the  velum  and  raise  the  pharynx. 
6 


74 


ORGANS    OF    DEGLUTITION. 


Azygos  Uvuhv  arises  from  the  posterior  spine  of  the  palate 
bones  at  the  termination  of  the  palate  suture,  runs  along  the 
central  line  of  the  soft  palate,  and  ends  in  the  point  of  the  uvula. 
It  raises  and  shortens  the  uvula. 

It  is  thus  seen  that  the  various  muscles  of  the  soft  palate  are 
all  concerned,  more  or  less,  in  conducting  the  food  into  the 
pharyngeal  cavity.  The  elevators  raise  the  palate,  and  at  the 
same  time  protect  the  posterior  nares  from  regurgitation  of  the 
food  ;  while  the  tensor  puts  it  on  the  stretch,  and  after  having 
passed  the  velum,  the  constrictor  isthmi-faucium  and  palato- 
pharyngeus  draw  the  palate  down,  and  thus  close  the  opening 
into  the  mouth ;  after  which  the  food,  as  already  mentioned,  is 
grasped  by  the  constrictor  muscles  of  the  pharynx,  and  conveyed 
into  the  oesophagus. 


The 


Fig.  39. 


Tonsils  are  two  bodies,  each  about  the  size  of  an  almond, 
seen  at  the  root  of  the  tongue  on  its 
sides,  occupying  the  cavity  between 
the  anterior  and  posterior  half  arches. 
They  consist  of  a  group  of  compound 
follicular  glands,  forming  somewhat 
oval  bodies,  whose  enlargement  con- 
stitutes an  obstacle  to  deglutition, 
and  by  their  locality  near  the  mouths 
of  the  Eustachian  tubes,  frequently 
cause  obstruction  and  deafness. 

THE  TONGUE. 


The  Tongue  is  a  very  complicated 
organ,  for  it  consists  of  a  great 
variety  of  parts,  and  performs  a 
great  variety  of  functions ;  and 
although  w6  have  arranged  it  here, 
as  one  of  the  organs  (^.deglutition, 
it  is,  besides — a  glandular  organ,  to 
secrete ;  a  sentient  organ,  to  feel  and 
taste ;  and,  likewise,  an  intellectual 
organ,  to  assist  in  producing  speech. 


Fio.  ^9.  A  front  view  of  the  upper  sur- 
face of  the  tongue  and  palatine  arch  ;  a  a 
Posterior  lateral  half  arches,  containing 
the  palato-pharyngei  muKcles  and  the 
tonsilH  ;  b  Epiglottis  cartilage  ;  c  c  Liga- 
ment and  mucou.s  iiiembrane,  extending 
from  root  of  tongue  to  ba.se  of  epigloltis 
cartilage;  rf  Foramen  csecum  or  central 
lenticular  papilla  ;  e  Lenticular  papilla; ;/ 
Filiform  papillx;  ji  Conical  papilla;,  .scat- 
tered over  whole  surface  .t)f  the  tongue  ;  h 
Point  of  tongue  ;  i  i  Fungiform  papills 
seen  on  borders  of  the  tongue. 


ORGANS    OF    DEGLUTITION.  75 

The  tongue  is  divided  into  apex,  body  and  root ;  the  apex  is 
the  anterior  free  and  sharp  portion  ;  the  root  which  is  thin,  is 
attached  to  the  os-hyoides  and  is  posterior ;  while  the  body, 
which  occupies  the  centre,  is  thick  and  broad ;  it  is  confined  in 
its  situation  by  the  origins  of  its  component  muscles,  and  by 
reflections  of  the  mucous  membrane,  to  be  noticed  hereafter. 

The  upper  surface  is  rough  from  numerous  eminences  called 
the  papillae — which  are  distinguished  into  :  1.  The  Lenticular  ; 
2.  The  Fungiform ;    3.  The  Conical ;  and,  4.  Filiform  papillae. 

The  Lenticular  are  the  largest  in  size,  situated  at  the  root  of 
the  tongue,  are  nine  or  more  in  number,  and  arranged  after  the 
manner  of  the  letter  V,  with  the  concavity  looking  forwards. 

They  are,  generally,  conical  in  shape,  surrounded  by  a  slight 
annular  elevation,  and  consist  simply  of  mucous  follicles  like 
those  of  the  lips,  palate,  etc.  Behind  these  is  observed  a  de- 
pression called  the  foramen  caecum,  into  which  open  a  group  of 
lingual  glands. 

The  Fungiform  are  next  in  size,  and  more  numerous ;  they 
are  found  near  the  borders  of  the  tongue,  and  present  a  rounded 
head  supported  on  a  thin  pedicle. 

The  Conical  are  still  more  numerous,  and  are  seen  scattered 
over  the  whole  surface  of  the  tongue,  reaching  from  the  lenticu- 
lar glands  to  the  apex.  They  are  minute  and  tapering,  and 
resemble  small  cones. 

The  Filiform  papillae  are  the  smallest  of  all,  and  occupy  the 
intervals  between  the  others,  and  are  also  found  at  the  apex  of 
the  tongue. 

All  these  papillae,  except  the  lenticular,  from  their  being  so 
freely  supplied  with  mucous  and  blood  vessels,  and  having  a 
peculiar  arrangement,  belong  essentially  to  the  function  of  taste. 

The  great  body  of  the  tongue,  however,  is  muscular  in  its 
structure,  and  its  muscles  are  as  follows : 

1.  The  Stylo-Glossus. 

2.  Hyo-Glossus. 

3.  Genio-Hyo-Glossus. 

4.  Lingualis. 


76 


ORGANS    OF   DEGLUTITION. 


These  constitute  the  muscles  proper  of  the  tongue.  But  there 
are  some  others  which  act  more  or  less  indirectly  on  the  tongue 
and  lower  jaw.     They  are 

1.  The  Digastricus, 

2.  The  Mylo-Hyoideus,  and 

3.  The  Genio-Hyoideus. 

The  Stt/lo-Glossns  arises  from  the  point  of  the  styloid  pro- 
cess and  stylo-maxillary  ligament.  It  is  inserted  into  the  side 
of  the  tongue  near  its  root,  its  fibres  running  to  the  tip. 


The  Hyo-Qlossus — a  thin,  broad,  quadrilateral  muscle,  has 
its  origin  fi-om  the  body,  cornu,  and  appendix,  of  the  os-hyoides, 
and  is  inserted  into  the  side  of  the  tongue,  forming  the  greater 
part  of  its  bulk. 

Fig.  40. 


Fio.  40.  Lateral  view  of  tODgne  and  its  principal  muscles  :  a  Mastoid  process  ;  6(!oronoid  pro- 
cess;  cStylo-glossns  mnscle  ;  d  Hyo-glossus  muscle  ;  e  Genio-hyo-glossas  muscle;  /Genio-hyoid 
muscle :  fir  Section  of  lower  jaw  at  symphysis  ;   /t  Styloid  process. 

The  Genio-fft/o-Glos8U3  is  a  triangular  muscle,  situated  on 
the  inside  of  the  last,  and  having  its  origin  from  the  upper  tu- 
bercle on  the  posterior  symphysis  of  the  lower  jaw,  and  its  in- 
sertion into  the  body  of  the  os-hyoides  and  the  whole  length  of 


ORGANS    OF    DEGLUTITION.  77 

the  tongue  from  its  base  to  its  apex.     The  fibres  of  this  muscle 
radiate  in  various  directions  through  the  tongue. 

The  Lingualis  has  its  origm  on  the  under  surface  of  the 
tongue,  extending  from  its  base  and  the  hyoid  bone  to  the 
apex,  and  so  intermingling  with  the  other  muscles  as  to  be  con- 
sidered rather  a  part  of  them  than  a  distinct  muscle. 

The  Digastricus,  as  its  name  implies,  consists  of  two  bellies 
united  in  the  middle  by  a  tendon  which  passes  through  the  in- 
sertion of  the  stylo-hyoid  muscle,  and  is  attached  to  the  hyoid 
bone.  Of  the  two  bellies,  one  is  posterior,  and  occupies  the 
fossa  at  the  end  of  the  mastoid  process  of  the  temporal  bone ; 
the  other  is  anterior,  and  extends  from  the  os-hyoides  to  the 
base  of  the  lower  jaw  by  the  side  of  the  symphysis. 

The  Mglo-Hgoideus  forms  the  floor  of  the  mouth  and  is  a 
broad  plane  of  muscular  fibres,  having  its  origin  from  the  myloid 
ridge  on  the  posterior  surface  of  the  inferior  maxilla,  and  its 
insertion  into  the  body  of  the  os-hyoides. 

The  G-enio-Hyoideus  is  a  short,  round  muscle  beneath  the  last, 
and  has  its  origin  from  the  lower  tubercle  on  the  back  of  the 
symphysis  of  the  lower  jaw,  and  insertion  into  the  body  of  the 
os-hyoides. 

All  these  muscles,  by  their  separate  or  combined  action,  have 
the  power  of  throwing  the  tongue  into  every  possible  variety  of 
position  and  motion  concerned  in  the  functions  of  deglutition, 
suction  and  speech.  They  can  elevate,  depress  or  turn  the 
tongue  to  either  side;  they  can  protrude  it  from  the  mouth  or 
draw  it  back  to  the  pharynx  ;  make  its  upper  surface  or  dorsum 
either  convex  or  concave ;  and,  finally,  can  turn  the  tip,  as  is 
well  known,  either  upward,  downward,  backward  or  laterally. 

THE  MUCOUS  MEMBRANE  LINING  THE  MOUTH. 

The  whole  interior  cavity  of  the  mouth,  palate,  pharynx  and 
lips,  is  covered  by  mucous  membrane,  forming  folds  or  dupli- 
catures  at  different  points,  called  fraena  or  bridles.  Beginning 
at  the  margin  of  the  lower  lip,  this  membrane  can  be  traced 


78 


ORGANS    OF    DEGLUTITION. 


lining  its  posterior  surface,  and  from,  thence  reflected  on  the 
anterior  face  of  the  lower  jaw,  where  it  forms  a  fold  opposite 
the  symphysis  of  the  chin — the  frsenum  of  the  lower  lip;  it  is 
now  traced  to  the  alveolar  ridge,  covering  it  in  front,  and  passing 
over  its  posterior  surface,  where  it  enters  the  mouth.  Here  it  is 
reflected  from  the  posterior  symphysis  of  the  lower  jaw  to  the 
under  surface  of  the  tongue,  where  it  forms  a  fold  or  bridle 
called  the  frsenum  linguae.  It  now  spreads  over  the  tongue, 
covering  its  dorsum  and  sides  to  the  root,  from  whence  it  is  re- 
flected to  the  epiglottis,  forming  another  fold;  from  this  point 
it  can  be  followed,  entering  the  glottis  and  lining  the  larynx, 
trachea,  etc. 

In  the  same  way  commencing  at  the  upper  lip,  it  is  reflected 
to  the  upper  jaAv,  and  at  the  upper  central  incisors  forming  a 
fold,  the  frsenum  of  the  upper  lip;  from  this  it  passes  over  the 
alveolar  ridge  to  the  roof  of  the  mouth,  which  it  completely 
covers,  and  extends  as  far  back  as  the  posterior  edge  of  the 
palate  bones;  from  this  it  is  reflected  downwards  over  the  soft 
palate ;  or,  more  strictly  speaking,  the  soft  palate  is  formed  by 
the  duplicature  of  this  membrane  at  this  point,  between  the 
folds  of  which  are  placed  the  muscles  of  the  palate  already 
described. 

From  the  palate  it  is  traced  upward  and  continuous  with  the 
membrane  lining  the  nares,  and  downward  with  the  same  lining 
the  pharynx,  oesophagus,  stomach  and  intestinal  canal. 

The  mucous  membrane,  after  entering  the  nostrils  and  lining 
the  roof,  floor,  septum  nasi  and  turbinated  bones,  enters  the 
maxillary  sinus  between  the  middle  and  lower  spongy  bones,  and 
lines  the  whole  of  this  great  and  important  cavity  of  the  superior 
maxilla. 

Many  mucous  glands  or  follicles,  already  enumerated,  are 
scattered  over  the  whole  of  this  membrane,  and  furnish  the 
mouth  with  its  mucus. 

As  this  membrane  passes  over  the  superior  surface  of  the 
alveolar  ridge  of  both  jaws,  its  texture  becomes  changed,  and 
receives  the  name  of  gums. 


ORGANS  OF  DEGLUTITION.  79 

THE  GUMS. 

The  gums  are  composed  of  thick,  dense,  mucous  membrane, 
adhering  to  the  periosteum  of  the  alveolar  processes,  and  closely 
surrounding  the  necks  of  the  teeth,  where  they  are  reflected 
upon  themselves,  forming  a  free  border  or  margin,  presenting  a 
scalloped  or  festooned  appearance.  The  longest  portions  are 
situated  in  the  interdental  spaces  between  the  teeth.  The  re- 
flected portion  unites  with  the  periosteum  of  the  roots  at  the 
necks  of  the  teeth,  and  becomes  continuous  with  it.  The  tex- 
ture of  the  gums  difi'ers  materially  from  that  of  the  membrane 
with  which  they  are  covered.  Externally,  it  is  very  similar  to 
this  membrane,  but  internally,  it  is  fibro-cartilaginous.  The 
gums,  when  in  a  healthy  state,  vary  in  thickness  from  one-third 
to  three-fourths  of  a  line. 

The  gums  are  remarkable  for  their  insensibility  and  hardness 
in  the  healthy  state,  but  exhibit  great  tenderness  upon  the 
slightest  injury,  when  diseased. 

In  the  infant  state  of  the  gums,  the  central  line  of  each  dental 
arch  presents  a  white,  firm,  cartilaginous  ridge,  which  gradually 
becomes  thinner  as  the  teeth  advance ;  and  in  old  age,  after  the 
teeth  drop  out,  the  gums  again  resume  somewhat  their  former 
infantile  condition,  showing  "second-childhood." 

The  gums  being  endowed  with  a  high  degree  of  vascularity, 
indicate  very  correctly,  as  the  author  has  stated  in  another  part 
of  the  work,  the  state  of  the  constitutional  health. 

THE    ALVEOLO-DENTAL    PERIOSTEUM. 

This  membrane  may  be  properly  noticed  here,  as  it  is  con- 
sidered by  some  as  continuous  with  the  gums.  It  lines  the 
alveolar  cavities,  or  sockets  of  the  teeth,  covers  the  roots  of  each, 
is  attached  to  the  gums  at  the  necks,  and  to  the  blood-vessels 
and  nerves  where  they  enter  the  roots  of  the  teeth  at  their 
apices ;  and,  further,  Mr.  Thomas  Bell  believes  it  passes  into  the 
cavities  of  the  teeth,  forming  their  lining  membrane,  and  is  con- 
tinuous with,  or  the  same  as  that  of  the  pulp. 

The  original  sac  has  been  stated  in  another  place  to  consist  of 
two  membranes,  an  outer  and  an  inner ;  these  are  attached  to 
the  gums,  and  when  the  teeth  come  through  these  membranes 
and   the  gums,  the  sac  remaining  behind,  especially  its    outer 


80  ORGANS    OF    DEGLUTITION. 

coat,  is  supposed  by  some  to  constitute  the  alveolo-dental  perios- 
teum, and  to  be  continuous  with  the  gums — while,  on  the  other 
hand,  Mr.  Bell  believes  both  membranes  of  the  sac  to  be  wholly 
absorbed ;  and  that  the  true  alveolo-dental  periosteum  is  the 
same  as  the  periosteum  covering  the  upper  and  lower  maxillary 
bones,  continuing  into  the  alveolar  cavities,  lining  their  parietes, 
and  thence  being  reflected  on  the  roots  of  the  teeth. 

It  matters  little  whether  this  membrane  be  a  continuation  of 
the  gums,  the  remains  of  the  pulp  sac,  or  the  extension  of  the 
periosteum  of  the  maxillary  bones  into  the  alveolar  cavities, 
since  the  great  practical  truth  still  remains,  that  there  is  a  mem- 
brane lining  the  alveolar  cavities  and  investing  the  roots  of  the 
teeth,  and  that  this  membrane  is  fibrous,  and  constitutes  the  bond 
of  union  between  the  alveolar  cavities  and  the  roots  of  the  teeth. 

The  Dental  Ligament,  so  recently  discovered  by  a  dentist, 
formerly  of  Virginia,  but  now  of  Philadelphia,  as  attached  to 
the  necks  of  the  teeth,  and  whose  opinion,  I  am  sorry  to  add, 
has  the  support  of  Dr.  Goddard,  bears  no  more  resemblance  to 
true  ligament  than  the  nails  do  to  bone.  It  consists  of  the  fibres 
that  unite  the  alveolar  to  the  dental  periosteum,  and  which,  ac- 
cording to  the  last-named  gentleman,  '•  are  very  numerous  just 
at  the  margin  of  the  alveolus;"  but  it  can  lay  no  reasonable 
claim  to  the  title  of  ligament. 


CHAP  TER     FIFTH. 

BLOOD-VESSELS    OF    THE    MOUTH. 

The  arteries  that  supply  the  mouth  come  from  the  external 
carotid.     This  is  a  division  of  the  common  carotid  which  arises 

Fig.  41. 


Fro.  41.  A  view  of  the  artHi-ies  supplying  one  .side  of  the  moutli  and  face  :  a  a  External  carotid 
artery  ;  b  Inferior  maxillary  bona  with  the  anterior  plate  removed  t^o  as  to  expose  the  roots  of 
the  teeth  and  the  inferior  dental  artery  ;  c  Po,«terior  mental  foramen,  through  which  the  inferior 
dental  artery  passes;  d  Anterior  mental  foramen,  wliere  the  same  artery  comes  out  to  supply  the 
muscles  of  the  lower  lip  ;  e  e  Superior  maxillary  bone,  with  the  lower  part  of  the  anterior  and 
outer  wall  removed,  showing  the  arteries  going  to  the  roots  of  the  teeth  and  cavity  of  the  an- 
trum ;  /  Infra-orbital  forameu,  through  which  passes  the  infra-orbital  ariery  ;  h  Nasal  process  of 
superior  maxillary  bone  ;  i  Pterygoideus  interniis  mu.scle  ; ./  Angle  of  inferior  maxillary  bone  ; 
k  Orbit  of  the  eye  ;  I  Superior  thyroid  artery  ;  m  m  Facial  artery  ;  n  Terminating  branch  of  the 
lingual  artery  :  o  Termination  of  external  carotid  into  the  temporal  and  internal  maxillary 
branches  ;  p  Temporal  artery  ;  q  Internal  maxillary  artery ;  r  >•  Inferior  dental  ariery  ;  s  Deep 
temporal  branch  ;  t  Trausver.'^e  artery  of  the  face;  u  u  Muscular  branches  ;  v  Alveolar  branch  ; 
w  Posterior  denial  branch  ;  x  Terminal  branch  of  infra-orbital  arteiy  ;  y  Na.sal  branch  of  the 
facial ;  s  Submental  branch. 

on  the  right  side  from  the  arteria-innominata,  and  on  the  left 
from  the  arch  of  the  aorta ;  after  passing  up  the  neck  on  either 
side  along  the  course  of   the  sterno-cleido  mastoid    muscles,  it 


82  BLOOD-VESSELS    OF    THE    MOUTH. 

divides  on  a  level  with  the  top  of  the  thyroid  cartilage   into  its 
two  great  branches — the  external  and  internal  carotid  arteries. 

The  Internal  Carotid  Artery  has  a  tortuous  course,  is  first  to 
the  outside  and  behind  the  external  carotid  ;  then  ascends  in 
front  of  the  vertebral  column  by  the  side  of  the  pharynx  and 
behind  the  digastric  and  styloid  muscles  to  the  carotid  foramen 
in  the  petrous  portion  of  the  temporal  bone — thence  it  tra- 
verses the  canal  in  this  bone  and  enters  the  brain,  supplying  it 
with  the  most  of  its  vessels,  not  giving  any  to  the  mouth. 

The  External  Carotid  {a  a  Fig.  41)  extends  from  the  top  of 
the  larynx  to  the  neck  of  the  condyle  of  the  lower  jaw ;  at  first 
anterior  and  on  the  inside  of  the  internal  carotid,  it  soon  gets 
to  the  outside,  then  passes  under  the  digastric  and  stylo-hyoid 
muscles  and  lingual  nerve,  becomes  imbedded  in  the  parotid 
gland,  and  terminates  between  the  neck  of  the  inferior  maxilla 
and  the  auditory  meatus  in  the  temporal  and  internal  maxillary 
arteries. 

The  branches  of  this  artery  supply  all  the  organs  belonging 
to  the  four  primary  stages  of  digestion,  namely,  those  of  Pre- 
hengion,  Mastication,  Insalivation,  and  Deglutition. 


ARTERIES  OF  THE  ORGANS  OF  PREIIEXSIOX. 

These  belong,  principally,  to  the  lips,  and  come  chiefly  from 
the  facial  artery. 

The  Facial  Artery  is  the  third  branch  of  the  external  carotid. 
It  ascends  to  the  submaxillary  gland,  behind  which  it  passes  on 
the  body  of  the  lower  jaw — thence  it  goes  in  front  of  the  mas- 
seter  muscle  to  the  angles  of  the  mouth,  and,  finally,  terminates 
at  the  side  of  the  nose  by  anastomosing  with  the  ophthalmic 
arteries. 

In  its  course  it  gives  off  the  submental,  inferior  labial,  superior 
and  inferior  coronary  arteries,  which  mainly  supply  the  elevators, 
depressors,  and  circular  muscles  of  the  mouth — those  agents 
concerned  in  the  first  steps  of  digestion,  the  prehension  of  the 
food. 


BLOOD-VESSELS    OF   THE    MOVTH.  83 

ARTERIES  BELONGING  TO  THE  ORGANS  OF  MASTICATION. 

These  are  derived  from  the  internal  maxillary  and  the  tem- 
poral— the  two  terminating  branches  of  the  external  carotid. 

The  Internal  Maxillary  Artery  commences  in  the  substance 
of  the  parotid  gland ;  then  goes  horizontally  behind  the  neck  of 
the  condyle  of  the  lower  jaw  to  the  pterygoid  muscles,  between 
which  it  passes,  and  then  proceeds  forward  to  the  tuberosity  of 
the  superior  maxillary  bone ;  from  thence  it  takes  a  vertical 
direction  upward  between  the  temporal  and  external  pterygoid 
muscles  to  the  zygomatic  fossa,  where  it  again  becomes  hori- 
zontal, and,  finally,  ends  in  the  spheno-maxillary  fossa  by 
dividing  into  several  branches. 

Those  branches  of  the  internal  maxillary  supplying  the  passive 
organs  of  mastication,  or  the  superior  and  inferior  maxillary 
bones,  and  the  teeth,  are, 

1,   Inferior  Maxillary  or  Dental  Artery, 
•2.  The  Alveolar  or  Superior  Dental, 

3.  The  Infra-Orbital, 

4.  The  Superior  Palatine,  and 

5.  The  Spheno-Palatine. 

The  Inferior  Dental  Artery  enters  the  inferior  dental  foramen 
of  the  lower  jaw,  passes  along  the  dental  canal  beneath  the  roots 
of  the  teeth  ;  sending  up,  in  its  course,  a  twig  through  the  aper- 
ture of  each  to  the  pulps  of  the  teeth,  and,  finally,  escapes  at  the 
mental  foramen  on  the  chin ;  a  branch  of  it,  however,  continues 
forward  to  supply  the  incisors. 

The  Superior  Dental  Artery  winds  around  the  maxillary 
tuberosity  from  behind  forward,  sending  ofi"  twigs  through  the 
posterior  dental  canals  which  supply  the  molars  and  the 
maxillary  sinus ;  while  the  main  branch  is  continued  forward, 
furnishing  the  gums. 

The  Infra-Orbital  Artery  enters  the  infra-orbital  canal,  tra- 
verses its  whole  extent,  and  comes  out  at  the  foramen  of  the 
same  name,  upon  the  face  ;  just  before  it  emerges  it  sends  through 
the  anterior  dental  canal  a  twig  for  the  incisors  and  cuspids. 


84  BLOOD-VESSELS    OF   THE    MOUTH. 

The  Superior  Palatine  descends  behind  the  superior  maxil- 
lary bone,  passes  through  the  posterior  palatine  canal  to  the 
roof  of  the  mouth,  and  supplies  the  palate,  gums,  and  velum 
pendulum  palati.  It  also  sends  off  a  small  branch  through  the 
foramen  incisivum  to  the  nose. 

The  Spheno- Palatine,  entering  the  back  part  of  the  nose 
through  the  spheno-palatine  foramen,  is  distributed  upon  the 
pituitary  membrane. 

The  arteries  supplying  the  active  organs  of  mastication — the 
temporal,  masseter,  and  pterygoid  muscles — are : 

The  temporal,  anterior  and  posterior  deep ;  the  pterygoid  and 
masseteric  branches  of  the  internal  maxillary  artery ;  while  the 
temporal  artery,  which  is  the  other  terminating  branch  of  the 
external  carotid,  gives  off  the  middle  temporal  artery  to  the 
temporal  muscle,  and  a  branch,  the  transverse  artery,  to  the 
masseter. 

The  Temporal  Artery  begins  in  the  substance  of  the  parotid 
gland  at  the  neck  of  the  condyle  of  the  lower  jaw,  mounts  over 
the  zygoma  in  front  of  the  meatus,  and  ascends  about  an  inch 
or  more,  when  it  divides  into  anterior  and  posterior  branches. 


ARTERIES    SUPPLYING    THE     PARTS    CONCERNED    IN 
SALIVATION. 

These  belong  to  the  salivary  glands.  The  parotid  gland  is 
supplied  by  the  posterior  auricular,  a  branch  ©f  the  external 
carotid,  and  by  the  transverse  artery  of  the  temporal.  The 
submaxillary  gland  is  supplied  by  the  facial,  and  the  sublingual 
by  a  branch  of  the  lingual  artery. 

ARTERIES  BELONGING  TO  THE  ORGANS  OF  DEGLUTITION. 

The  pharynx,  soft  palate,  and  tongue,  are  the  organs  supplied 
by  these  arteries. 

The  Arteries  of  the  Pharynx  are  the  superior  and  inferior 
pharyngeal  and  inferior  palatine. 


BLOOD-VESSELS    OF   THE    MOUTH.  85 

The  superior  pharyngeal  is  a  branch  of  the  internal  maxillary, 
and  is  spent  upon  the  upper  part  of  the  pharynx,  and  sends  a 
branch  through  the  pterygo-palatine  foramen  to  supply  the  arch 
of  the  palate  and  contiguous  parts.  The  inferior  is  a  branch  of 
the  external  carotid,  and  in  its  course  upwards  towards  the  basis 
of  the  cranium,  it  sends  several  branches  to  the  pharynx  and 
contiguous  deep-seated  parts.  The  inferior  palatine  is  given  off 
by  the  facial. 

The  Arteries  of  the  Soft  Palate  are. 

The  superior  palatine,  inferior  palatine,  and  inferior  pharyn- 
geal branches. 

The  Superior  Palatine  is  derived  from  the  internal  maxillary 
behind  the  orbit  in  the  ptery go-maxillary  fossa ;  descends  through 
the  posterior  palatine  canal,  comes  out  on  the  back  part  of  the  roof 
of  the  palate  through  a  foramen  of  the  same  name,  and  proceeds 
inward  and  forward,  supplying  the  soft  palate  and  the  mucous 
membrane. 

The  Inferior  Palatine  is  a  branch  of  the  facial,  and  passes  up 
between  the  stylo-glossus  and  stylo-pharyngeus  muscles  to  the 
tonsil  and  soft  palate.  It  also  anastomoses  with  the  superior 
palatine  branch  of  the  internal  maxillary  artery.  The  inferior 
pharyngeal  is  a  branch  of  the  external  carotid. 

The  Arteries  of  the  Tongue  are  the  Lingual.  These  arteries, 
on  either  side,  arise  from  the  external  carotid,  run  forward 
above  and  parallel  with  the  os-hyoides  ;  then  ascend  to  the  under 
surface  of  the  tongue  as  far  as  the  tip,  under  the  name  of  the 
ranine  arteries.  They  give  oflf  numerous  branches  in  their  course, 
supplying  every  part  of  the  tongue. 

The  mucous  membrane  of  the  mouth  is  principally  supplied  by 
the  anterior  and  posterior  palatine,  and  the  facial  arteries ;  the 
gums  receive  the  alveolar  and  submental  branches. 

The  Branches  of  the  External  Carotid  artery  as  they  arise  in 
numerical  order,  are  as  follows  : 


86 


BLOOD-VESSELS    OF    THE    MOUTH. 


1.  The  Superior  Thyroid. 

2.  The  Lingual. 

3.  The  Facial. 

4.  The  Inferior  Pharyngeal. 

5.  Occipital. 

6.  Posterior  Auricular. 

7.  Temporal. 

S.  Internal  Maxillary. 

The  internal  maxillary,  being  the  great  artery  of  the  mouth, 
gives  off  branches  in  the  following  order: 


Origin,  behind  the  neck 
of  the  Condyle. 

Origin,  between  Ptery- 
goid Muscles. 

Origin,  Zygomatic 
fossa. 


Origin,  Spheno-Maxil- 
lary  fossa. 


1. 

2_ 

3. 
4. 

5. 
6. 

7. 


f     1.   Tympanic  Branch, 
Inferior  Dental, 
Greater  Meningeal, 
Lesser  Meningeal. 
Posterior  Deep  Temporal  Artery, 
Masseteric, 
Pterygoid  Arteries. 

8.  Buccal  Artery, 

9.  Anterior  Deep  Temporal, 

10.  Alveolar  or  Superior  Dental, 

11.  Inferior  Orbital. 

12.  Pterygoid  or  Vidian, 

13.  Superior  Pharyngeal, 
I    14.   Superior  Palatine, 

l^  15.  Spheno-Palatine  Artery, 


THE  VEINS. 


The  veins  correspond  so  nearly,  both  in  name  and  course  with 
the  arteries,  that  a  description  of  them  would  be  only  a  repeti- 
tion of  what  has  been  said ;  suffice  it,  therefore,  to  observe,  that 
there  are  two  companion  veins  with  every  considerable  artery,- 
and  that  the  venous  branches  are  mostly  collected  at  the  angle 
of  the  jaw  into  a  common  trunk  called  the  external  jugular  vein, 
which  passes  down  the  neck  in  the  course  of  the  fibres  of  the 
platysma  muscle,  and  terminates  in  the  subclavian  vein  at  the 
posterior  edge  of  the  sterno-mastoid  muscle. 

The  office  of  the  veins  is  to  return  the  blood  to  the  heart. 


CHAPTER   SIXTH. 

THE  NERVES  OF  THE  MOUTH. 

The  nerves  supplying  the  mouth  belong  to  the  fifth  pair,  and 
the  portio-dura  of  the  seventh  or  facial  nerve. 


Fig.  42. 


Fio.  42.  The  fifth  nerve  with  its  branches:  a  The  inferior  maxilliary  bone;  b  Inferior  dental 
foramen  where  tho  inferior  dental  nerve  enters  to  supply  the  teeth  ;  c  Inferior  dental  nerve ;  d  Gus- 
tatory branch  of  fifth  nerve  ;  e  Muscular  branch  of  inferior  maxillary  nerve; /Ophthalmic  nerve; 
g  Infra-orbital  fonimen  where  iiifra-orbltal  nerve  comes  out ;  h  Terminating  branches  of  inferior 
dental  nerve;  i  Casserian  ganglion  ;  j  Internal  view  of  maxillary  sinus;  k  Superior  maxillary 
nerve,  just  where  it  is  given  off  from  the  ganglion  ;  I  Posterior  dental  branch  (  f  superior  maxil- 
lary nerve  ;?»  Anterior  branch  of  superior  dental  nerve;  n  Terminating  branches  of  infra-orbital 
nerve;  o  Nasal  branch  of  ophthalmic  nerve  ;  p  Frontal  branch  of  ophthalmic  nerve. 

The  Fifth  (Trigemini)  are  the  largest  of  the  cranial  nerves, 
and  give  sensibility  to  all  the  organs  concerned  in  the  primary 
stages  of  digestion. 


88  NERVES    OF   THE    MOUTH. 

This  nerve  will  also  be  found  to  be  a  compound  nerve,  having 
motor  filaments  as  well  as  sensitive,  and  thereby  giving  motion 
as  well  as  sensation. 

It  is  first  seen  at  the  side  of  the  pons  Varolii  near  its  junction 
with  the  crura-cerebelli — but  its  origin  is  much  deeper  and  fur- 
ther back.  It  arises  by  two  unequal  roots,  one  of  which  may  be 
traced  through  the  pons  Varolii  into  the  restiform  body  and  the 
floor  of  the  fourth  ventricle ; — the  smaller,  or  motor  root,  is  lost 
in  the  medulla  oblongata.  From  its  origins  this  nerve  has  been 
called  a  cranial-spinal  nerve. 

These  two  fasciculi,  the  one  anterior  and  the  other  posterior, 
constitute  the  fifth  nerve,  which  consists  of  eighty  or  one  hun- 
dred filaments  that  pass  forward  and  outward,  in  a  canal  formed 
of  dura  mater,  to  a  depression  on  the  anterior  surface  of  the  pet- 
rous bone. 

At  this  point  it  spreads  into  a  ganglion,  called  the  Casserian 
ganglion,  on  the  under  surface  of  which  is  seen  the  anterior 
root;  but  it  has  no  intimate  connection  with  the  ganglion,  and 
can  be  traced  on,  as  will  be  presently  shown,  to  the  inferior 
maxillary  nerve. 

From  the  ganglion  of  Casserius  proceed  three  primary  branches, 
namely : 

1.  The  Ophthalmic:  the 

2.  Superior  Maxillary :  and  the 

3.  Inferior  Maxillary  Nerves. 

The  Ophthalmic  Nerve  is  a  short  trunk  that  enters  the  orbit 
through  the  foramen  lacerum  superius,  and  divides  into  three 
principal  branches, 

1.  The  Frontal, 

2.  The  Lachrymal,  and 

3.  The  Nasal. 

The  Frontal  passes  along  the  roof  of  the  orbit  to  the  supra- 
orbital foramen,  through  which  it  passes,  and  is  then  called  the 
supra-orbital  nerve,  and  is  spent  on  the  muscles  and  integuments 
of  the  forehead.     It  gives  ofi"  several  branches  in  its  course. 

The  Lachrymal,  as  the  term  implies,  goes  to  the  lachrymal 


NERVES   OF   THE    MOUTH.  89 

gland,  taking  the  outward  direction,  and  sending  branches  in  its 
course  to  the  upper  eyelid,  conjunctiva  and  other  parts. 

The  Nasal  takes  its  direction  along  the  inner  side  of  the  orbit 
to  the  anterior  ethmoidal  foramen,  through  which  it  passes  into 
the  cranium,  on  the  upper  surface  of  the  cribriform  plate  of  the 
ethmoidal  bone  ;  descends  bj  the  side  of  the  crista-galli  through 
a  slit-like  opening  into  the  nose,  and  there  terminates  by  fila- 
ments which  are  spent  upon  the  septum,  mucous  membrane, 
anterior  nares,  etc.  It  sends  off  several  branches  in  its  course ; 
one  in  particular  to  the  lenticular  ganglion  at  the  bottom  of  the 
eye,  others  to  the  caruncula  lachrymalis,  lachrymal  sac,  conjunc- 
tiva, etc. ;  but  as  these  do  not  belong  to  the  mouth  and  dental 
apparatus,  we  will  pass  to  the  second  great  division  of  the  fifth. 

THE  SUPERIOR  MAXILLARY  NERVE. 

This  nerve  proceeds  from  the  middle  of  the  Casserian  gan- 
glion, passes  through  the  foramen  rotundum  of  the  sphenoid 
bone,  into  the  pterygo-maxillary  fossa;  here  it  enters  the  canal 
of  the  floor. of  the  orbit — the  infra-orbital  canal,  traverses  its 
whole  extent,  and  emerges  on  the  face  at  the  infra-orbital  fora- 
men, where  it  terminates  in  numerous  filaments  in  the  muscles 
and  integuments  of  the  upper  lip  and  cheek. 

The  superior  maxillary  nerve  supplies  the  upper  jaw,  and 
gives  ofi"  many  important  branches,  which  are  as  follows: 

In  the  pterygo-maxillary  fossa  two  branches  descend  to  a 
small  reddish  body  called  the  ganglion  of  Meckel,  or  the  spheno- 
palatine ganglion,  situated  on  the  outer  side  of  the  nasal  or 
vertical  plate  of  the  palate  bone. 

From  this  ganglion  proceed  three  sets  of  branches: 

1.  Inferior,  Descending,  or  Palatine  Nerves. 

2.  Nasal,  or  Spheno-palatine. 

3.  Posterior,  Pterygoid,  or  Vidian. 

The  Palatine  Nerves  descend  through  the  posterior  palatine 
canal,  come  out  at  the  posterior  palatine  foramen  along  with  an 
artery  of  the  same  name,  and  supply  with  filaments  the  soft 
palate,  uvula,  tonsils,  the  roof  of  the  mouth,  and  the  inner 
alveoli  and  gums. 
7 


90  NERVES    OF   THE    MOUTH. 

The  Nasal  Nerves  enter  the  nose  through  the  spheno-palatine 
foramen,  and  divide  into  several  filaments  which  enter  the  mucous 
membrane  covering  the  upper  and  lower  turbinated  bones  and 
vomer ;  one  long  branch  can  be  traced  along  the  septum  nasi  as 
far  as  the  foramen  incisivum,  where  it  meets  the  anterior  palatine 
branches  in  a  ganglion  called  the  naso-palatine. 

The  Vidian,  or  Pterygoid,  passes  backward  from  the  ganglion 
of  Meckel  through  the  pterygoid  canal  at  the  root  of  the  ptery- 
goid process ;  then  enters  the  cranium  through  the  foramen 
lacerum  anterius,  and  divides  into  two  branches,  one  of  which 
enters  the  carotid  canal  and  unites  with  the  sympathetic  branches 
of  the  superior  cervical  ganglion,  thus  connecting  this  ganglion 
with  the  ganglion  of  Meckel. 

The  other,  the  proper  vidian  nerve,  enters  the  vidian  foramen 
or  hiatus  Fallopii  in  the  petrous  bone,  joins  the  portio-dura  nerve, 
accompanies  this  as  far  as  the  back  part  of  the  tympanum  ;  then 
leaves  it,  enters  the  cavity  of  the  tympanum,  and  receives  here 
the  name  of  Chorda  Tym'pani.  It  leaves  this  cavity  by  the 
glenoid  fissure,  then  joins  the  gustatory  nerve,  continues  with  it 
to  the  submaxillary  gland,  where  it  leaves  it  and  is  lost  in  the 
submaxillary  ganglion,  situated  at  the  posterior  part  of  the  sub- 
maxillary gland. 

The  exceedingly  intricate  course  of  the  vidian  nerve  is  interest- 
ing from  the  number  of  communications  which  it  establishes 
between  different  and  distant  parts :  for  it  unites  the  ganglion  of 
Meckel  with  the  superior  cervical  ganglion  of  the  sympathetic, 
and  both  with  the  submaxillary  ganglion  ;  it  also  connects  the 
superior  and  inferior  maxillary  nerves  to  one  another  and  to  the 
portio-dura. 

The  Superior  Maxillary  Nerve  gives  ofi"  next  in  the  spheno- 
maxillary fossa : 

1.  The  Orbital. 

2.  The  Posterior  Dental  Nerve. 

The  Orbital  enters  the  orbit  through  the  spheno-maxillary 
fissure,  and  then  sends  ofi"  a  malar  and  temporal  branch,  which 
pass  out  through  the  malar  bone ;  the  first  supplying  the  cheek. 


NERVES    OF   THE    MOUTH.  91 

the  latter  accompanying  the  temporal  artery  to  the  integuments 
of  the  side  of  the  head. 

The  Posterior  Dental  I^erves,  three  or  four  in  number,  descend 
on  the  tuberosity  of  the  superior  maxillary  bone,  and  enter  the 
posterior  dental  canals  to  supply  the  molar  teeth;  one  branch 
penetrates  the  antrum  and  courses  along  the  outer  wall,  anasto- 
mosing with  the  anterior  dental  nerves,  while  another  runs 
along  the  alveolar  border  supplying  the  gums. 

The  superior  maxillary  nerve  now  enters  the  infra-orbital 
canal,  and  becomes  -the  infra-orbital  nerve,  which  is  its  terminat- 
ing branch. 

The  Infra-Orbital  nerve  advances  through  the  canal  of  the 
same  name,  and  gives  off  no  branch  until  it  arrives  at  the  fore- 
part ;  where  it  sends  down  along  the  front  of  the  maxillary  sinus, 
in  the  anterior  dental  canal,  the  anterior  dental  nerve,  which 
divides  so  as  to  supply  the  incisors,  cuspids  and  bicuspids,  and 
also  the  mucous  membrane  lining  the  antrum. 

This  nerve  now  emerges,  as  before  mentioned,  at  the  infra- 
orbital foramen,  between  the  levator  labii  superioris  alasque  nasi 
and  levator  anguli  muscles,  dividing  here  into  many  branches  ; 
some  of  which  ascend  to  the  nose  and  eyelids,  others  pass  down- 
ward and  outward  to  the  lip  and  cheek,  anastomosing  with  the 
nasal  branch  of  the  ophthalmic,  and  the  facial  branches  of  the 
portio-dura. 

INFERIOR  MAXILLARY  NERVE. 

This  nerve  forms  the  third  great  division  of  the  fifth.  It  is 
the  largest  branch,  and  passes  from  the  ganglion  of  Casser 
through  the  foramen  ovale  of  the  sphenoid  bone  to  the  zygo- 
matic fossa. 

This  nerve,  as  stated,  is  attached  to  the  anterior  or  motor 
root,  and  they  come  together  on  the  outside  of  the  foramen 
ovale :  then  in  the  zygomatic  fossa,  the  inferior  maxillary  nerve 
divides  into  two  branches  : 

1.  An  External,  Superior,  or  Smaller. 

2.  An  Internal,  Inferior,  or  Greater. 


92  NERVES    OF   THE   MOUTH. 

The  External  is  the  motor  branch,  and  gives  off  the  following 
filaments  to  the  several  muscles: 

1.  Masseteric^  crossing  the   Sigmoid  notch  to  the  Mas- 

seter  Muscle. 

2.  Temporal^  Anterior  and  Posterior  Deep,  to  the  Tem- 

poral Muscle  and  Fascia,  etc. 

3.  Buccal,  to  the  Buccinator,  etc. 

4.  Pterygoid,  to  the  Pterygoid  Muscles. 

The  Internal  division  of  the  inferior  maxillary  nerve  consists 
of  three  branches,  all  of  which  are  sensitive;  they  are: 

1.  The  Anterior  Auricular, 

2.  The  Gustatory,  and 

3.  The  Inferior  Dental. 

The  Anterior  Auricular  passes  behind  the  neck  of  the  lower 
jaw  and  in  front  of  the  meatus  of  the  ear,  and  ascends  through 
the  parotid  gland,  over  the  zygoma  along  with  the  temporal 
artery,  and  divides  into  anterior  and  posterior  branches. 

In  its  course  it  unites  with  the  facial  nerve,  and  supplies  the 
parotid  gland,  the  articulation  of  the  lower  jaw,  the  meatus,  and 
cartilages  of  the  ear  and  side  of  the  head. 

The  Gustatory  Nerve,  immediately  after  its  origin,  sends  a 
branch  to  the  inferior  dental ;  it  then  descends  between  the 
pterygoid  muscles,  where  the  chorda  tympani  joins  it ;  it  now 
passes  along  the  ramus  of  the  lower  jaw,  covered  by  the  internal 
pterygoid  muscle,  then  above  the  submaxillary  glands,  and  for- 
wards above  the  mylo-hyoid  and  between  it  and  the  hyo-glossus 
muscles,  accompanied  by  the  duct  of  Wharton ;  and  finally 
ascends  above  the  sublingual  gland  to  the  lateral,  inferior  and 
anterior  parts  of  the  tongue. 

In  its  course,  Mr.  Harrison  enumerates  the  following 
branches  as  given  off  by  this  nerve  : 

"  First,  one  or  two  small  filaments  to  the  internal  pterygoid 
muscle.  Second,  several  to  the  tonsils,  to  the  muscles  of  the 
palate,  to  the  upper  part  of  the  pharynx,  and  to  the  mucous 
membrane  of  the  gums.     Third,  the  chorda  tympani,  and  some 


NERVES   OF   THE    MOUTH.  93 

accompanying  filaments  to  form  a  plexus,  which  supplies  the 
submaxillary  gland.  Fourth,  a  few  branches  which  descend 
along  the  hyo-glossus  muscle  to  communicate  with  the  ninth  or 
lingual  nerve.  Fifth,  a  fasciculus  of  nerves  to  the  sublingual 
gland  and  to  the  surrounding  mucous  membrane.  Lastly,  at 
the  tongue  it  divides  into  several  branches,  some  pass  deep  into 
the  tissue  of  this  organ,  others,  firm  and  soft,  rise  toward  its  sur- 
face, and  are  lost  in  the  mucous  membrane  and  in  a  small  conical 
papilla  near  its  tip." 

The  Inferior  Dental  Nerve  passes  between  the  pterygoid 
muscles,  then  along  the  ramus  of  the  lower  jaw  under  the  ptery- 
goideus  internus  to  the  inferior  dental  foramen,  which  it  enters 
along  with  an  artery  and  vein  ;  it  now  traverses  the  inferior  dental 
canal,  sending  off  twigs  into  all  the  roots  of  the  molars  and 
bicuspids.  Opposite  the  mental  foramen  it  divides  into  two 
branches,  the  smaller  is  continued  forward  in  the  substance  of 
the  jaw  to  supply  the  roots  of  the  cuspids  and  incisors ;  while 
the  larger  comes  out  at  the  mental  foramen,  is  distributed  to  the 
muscles  and  integuments  of  the  lower  lip,  and,  finally,  communi- 
cates with  the  facial  nerve. 

The  inferior  dental,  just  as  it  enters  the  posterior  dental  fora- 
men, gives  off"  the  viylo-hyoid  nerve  ;  this  passes  forwards  in  a 
groove  of  the  lower  jaw,  and  supplies  the  mylo-hyoid,  genio- 
hyoid and  digastric  muscles. 

THE  FACIAL  NERVE. 

The  Portio-dura  of  the  seventh  or  facial  nerve  is  the  last 
nerve  to  be  noticed  as  particularly  belonging  to  the  mouth. 

The  Facial  Nerve  arises  from  the  medulla  oblongata  between 
the  olivary  and  restiform  bodies,  close  behind  the  lower  margin 
of  the  pons  Varolii ;  it  then  passes  forward  and  outward  with 
the  portio-mollis,  to  the  foramen  auditorium  internum,  which  it 
enters  and  passes  on  to  the  base  of  this  opening ;  here  these 
two  nerves  separate,  the  portio-mollis  going  to  the  labyrinth  of 
the  ear ;  while  the  facial  enters  the  aqueduct  of  Fallopius,  in 
which  it  is  joined  by  the  vidian  ;  it  then  goes  in  a  curved 
direction  outward  and  backward  behind  the  tympanum,  where 


94 


NERVES    OF   THE   MOUTH. 


it  parts  with  the  vidian,  and  proceeds  on  to  the    stvlo-mastoid 

foramen,  from  which  it  emer- 
ges. At  this  point  it  sends 
off  three  small  branches  : 

1.  The  Posterior  Auri- 
cular, 

2.  The  Stylo-Hyoid,  and 

3.  The  Digastric. 

The  Posterior  Auricular  as- 
cends behind  the  ear,  crosses 
the  mastoid  process  to  the 
occipito-frontalis  muscle. 

The  Stylo-Hyoid  is  distri- 
buted to  the  stylo-hyoid 
muscle. 

The  Digastric  is  distributed 
to  the  posterior  belly  of  the 
digastric  muscle. 


■f  <    '  t  '-^i 
d  ■■:  I  \i  ] 


^       ^ 


\  ViJ^ 


Fic.  43.  View  of  the  facial  uri  vr,  ..i  pLiiiuduia  of 
the  seventh  p.iir;  a  Trunk  of  the  facial  nerve;  b 
Ascending  branch  ;  e  Descending  branch  ;  d  Posterior 
auricular  branch  ;  e  e  Temporal  branches ;// Malar 
branches;  p  </ Inferior  maxillary  branches;  h  Pos- 
terior or  great  occipital  nerve ;  i  Terminal  branches 
of  the  inferior  dental  nerve  :  j  Terminal  branches  of 
infra-orbital  nerve  ;  k  k  Supra-orbital  nerve  and  its 
branches;  /  Orbicularis  oris;  m  Zygomalicus  major; 
n  Zygomaticus  minor;  o  Levator  labii  superioris 
alseque  nasi ;  p  Orbicularis  palpebrarum ;  q  De- 
pressor angali  oris. 


The  facial  nerve  while  deeply  imbedded  in  the  substance  of 
the  parotid  gland  divides  into  two  sets  of  branches,  of  which  one 
is  superior  and  the  other  inferior ;  these  two  by  frequent  unions 
form  the  pes  anserinns  or  parotidean  plexus,  and  send  branches 
to  the  whole  of  the  side  of  the  face. 

The  upper  division,  called  the  temporo-facial,  ascends  in  front 
of  the  ear  upon  the  zygoma,  accompanies  the  temporal  artery 
and  its  branches,  supplying  the  side  of  the  head,  ear,  and  fore- 
head, and  anastomosing  with  the  occipital  and  supra-orbital 
nerves;  a  set  of  branches  pass  transversely  to  the  cheek,  fur- 
nishing the  lower  eyelid,  lips,  side  of  the  nose,  and  uniting  with 
the  infra-orbital  nerve. 


The  inferior  or  cervico-facial  division  descends,  supplying  the 
lower  jaw  and  upper  part  of  the  neck,  giving  off  the  following 
branches : 


NERVES    OF    THE    MOUTH.  95 

1.  Buccal, 

2.  Inferior  Maxillary,  and 

3.  Cervical. 

The  Buccal,  or  superior  branches,  supply  the  muscles  of  the 
cheek,  nose,  and  upper  lip. 

The  Inferior  Maxillary  nerves  are  distributed  in  the  muscles 
of  the  chin  and  lower  lip,  and  by  means  of  anastomodic  branches 
communicate  with  the  inferior  dental  nerve. 

The  Cervical  branches  form  a  close  connection  with  the  supe- 
rior cervical  nerves,  and  supply  the  platysma-hyoid  muscle. 

The  facial  is  the  motor  nerve  of  the  face,  and  by  its  means 
the  passions  or  emotions  find  their  expression  in  the  peculiar 
action  of  the  muscles  to  which  it  is  distributed.  According  to 
the  system  of  Sir  Charles  Bell,  the  seventh  is  one  of  the  respi- 
ratory nerves. 

In  consequence  of  the  numerous  communications  which  this 
nerve  has  with  other  nerves,  the  name  of  Sympatheticus  Minor 
has  been  given  to  it  by  some  anatomists. 

Having  now  very  briefly  described  the  anatomical  elements  of 
the  several  organs  of  the  mouth,  it  may  be  well  to  notice,  in 
conclusion,  the  anatomical  and  physiological  relations  of  this 
cavity. 

ANATOMICAL  RELATIONS  OF  THE  MOUTH. 

The  mouth  has  many  interesting  anatomical  relations  with  the 
rest  of  the  body,  a  few  of  which  it  may  be  well  to  mention. 

By  means  of  its  lining  mucous  membrane  it  is  connected 
through  continuity  of  structure  with  the  pharynx,  oesophagus, 
stomach,  and  the  whole  of  the  intestinal  canal,  &c. 

Disease  still  further  establishes  this  structural  relation.  In- 
flammation, ulceration,  or  any  other  pathological  change  in  the 
stomach  or  intestines  is  felt  and  reported  on  the  tongue,  gums, 
and  other  parts  of  the  mouth,  showing  the  sympathy  and  the 
close  relationship  of  these  several  parts. 


96  NERVES    OF   THE    MOUTH. 

The  mouth  is  also  connected  bj  the  same  mucous  membrane 
with  the  organs  of  respiration  by  being  continued  down  into  the 
larynx,  trachea,  and  bronchi. 

Wide  spread  sympathies  are  established  between  the  mouth 
and  other  parts  by  means  of  the  numerous  nerves  which  animate 
the  parts  constituting  its  boundaries  and  lying  in  its  cavity,  as 
the  sympathetic,  the  seventh,  the  glosso-pharyngeal,  the  par- 
vagum,  the  hypoglossal,  and  the  upper  cervical. 

Simple  irritation  from  teething  has  frequently  thrown  children 
into  convulsions,  and  in  adults  tooth-ache  often  creates  extreme 
irritability  of  the  whole  nervous  system.  But  it  is  not  necessary 
to  dwell  here  on  the  sympathies  of  the  mouth  in  disease  with 
other  parts  of  the  body,  as  the  author  will  have  occasion  to  do 
this  in  other  parts  of  the  work.  It  will  be  well,  however,  to 
mention  in  this  place  that  there  is  a  general  anatomical  relation 
of  the  mouth  with  the  rest  of  the  body,  by  means  of  the  blood- 
vessels and  areolar  tissue. 

PHYSIOLOGICAL   RELATIONS. 

It  has  been  shown  that  the  mouth  consists  of  a  great  variety 
of  parts,  and,  also,  that  it  has  an  equally  great  diversity  of 
functions. 

The  fuctions  of  the  mouth  have  been  stated  to  be  those  of 
prehension,  mastication,  insalivation  and  deglutition. 

These  functions,  it  has  been  seen,  are  all  closely  related  to 
one  another,  and  mutually  dependent;  and  how  beautiful  is  the 
harmony  of  action  as  well  as  its  regular  and  orderly  succession  ! 
We  see,  in  the  first  place,  the  prehensile  instruments  laying  hold 
of  and  introducing  the  food  into  the  mouth;  then  the  organs  of 
mastication,  the  teeth  and  upper  and  lower  jaw  bones,  put  into 
operation  by  the  temporal,  masseter  and  pterygoid  muscles, 
grind  it  down  into  minute  portions ;  these  at  the  same  time  are 
formed  into  a  bolus  by  being  mixed  with  the  salivary  fluids, 
furnished  by  the  parotid,  submaxillary  and  sublingual  glands  ; 
then  the  mass  is  taken  by  the  organs  of  deglutition,  namely, 
the  tongue,  palate  and  pharynx,  and  passed  into  the  oesophagus, 
to  be  thence  conducted  into  the  stomach,  thus  demonstrating  the 
harmony  existing  among  the  several  functions  belonging  to  the 
mouth. 


NERVES    OF   THE    MOUTH.  97 

But  the  functional  relation  of  the  mouth  is  no  less  extensive 
than  its  structural  relation ;  the  one  is  commensurate  with  the 
other ;  and  as  the  structure  of  the  mouth  has  been  shown  to  be 
continuous  with  that  of  other  parts  of  the  body,  so  we  find  that 
the  functions  of  the  mouth  exert  an  influence  upon,  and  are 
themselves  influenced  by  many  great  and  leading  functions  of 
the  body.  The  connection  between  mastication  and  insalivation, 
for  example,  with  stomachal  digestion,  or  chymification,  is 
especially  obvious. 

Again,  the  mouth  is  intimately  related  with  the  intellectual 
functions,  as  for  instance,  that  of  speech.  Who  does  not  know 
that  when  any  of  the  teeth  are  wanting,  the  palate  cleft,  or  there 
is  a  hare-lip,  how  much  the  speech  is  impaired  ?  And  so  with 
all  the  other  functions  of  the  body ;  the  relation  between  them 
and  the  mouth,  and  the  mutual  dependence  of  each  on  the 
other,  is  equally  demonstrable. 

The  Origin,  Formation  and  Development  of  the  Teeth  ought 
now  to  engage  attention,  and  to  these  subjects  the  next  chapter 
is  devoted. 


CHAPTER     SEVENTH. 
ORIGIN  AND   FORMATION   OF   THE   TEETH. 

Of  all  the  operations  of  the  animal  economy,  none  are  more 
curious  or  interesting  than  that  which  is  concerned  in  the  pro- 
duction of  the  teeth.  In  obedience  to  certain  developmental 
laws,  established  by  an  all-wise  Creator,  it  is  cai-ried  on  from 
about  the  sixth  week  of  intra-uterine  existence,  with  the  nicest 
and  most  wonderful  regularity  until  completed,  but  so  secretly 
conducted,  as  to  prevent  the  closest  scrutiny  from  detecting  with 
precision  the  manner  in  which  it  is  effected;  enough,  however, 
is  ascertained  from  its  progressive  results  to  excite  in  the  mind 
of  the  physiologist  the  highest  admiration. 

From  small  papillae,  observable  at  a  very  early  period  of  foetal 
life,  situated  in  a  groove  lined  with  mucous  membrane,  and 
running  along  the  alveolar  border  of  each  jaw,  the  teeth  are 
gradually  developed.  As  they  increase  in  size,  the  papillae 
assume  the  shape  of  the  crowns  of  the  several  classes  of  teeth 
they  are  respectively  destined  to  produce.  Having  arrived  at 
this  stage  of  their  formation,  they  now  begin  to  dentinify,  first 
upon  the  cutting  edges  of  the  incisors,  the  apices  of  the  cuspids, 
bicuspids  and  eminences  of  the  molars ;  from  thence  the  process 
is  continued  over  the  whole  surface  of  their  crowns,  until  they 
become  invested  with  a  complete  layer  of  dentine ;  and  so  layer 
after  layer  is  formed,  one  within  the  other,  until  the  process  of 
solidification  is  completed.  But  before  it  has  progressed  very 
far,  the  enamel  of  the  teeth  begins  to  form,  and  this  formative 
operation  is  gone  through  with  previously  to  the  completion  of 
the  dentinification  of  the  pulps. 

In  the  meantime,  and  in  anticipation  of  the  fall  of  the  tem- 
porary teeth,  a  second  set  is  forming,  and  as  the  teeth  of  the  one 
series  are  removed,  they  are  promptly  replaced  by  those  of  the 
other.  Thus,  by  a  beautiful  and  most  admirable  provision  of 
nature,  the  first  set  of  teeth,  intended  to  subserve  the  wants  only 


ORIGIN    AND    FORMATION    OF    THE    TEETH.  99 

of  childhood  while  the  jaws  are  too  small  for  the  reception  of 
such  as  are  required  for  an  adult,  are  removed  and  replaced  by 
a  larger,  stronger  and  more  numerous  set. 

The  older  writers,  regarding  a  knowledge  of  the  earlier  stages 
of  the  development  of  the  teeth  as  not  of  much  importance, 
paid  little  attention  to  the  subject,  and  hence  this  most  curious 
and  interesting  department  of  developmental  anatomy  has  re- 
mained, until  recently,  measurably  uncultivated.  Eustachius, 
we  believe,  was  the  first  to  notice  the  position  and  arrangement 
of  the  teeth  in  the  jaws  previous  to  their  eruption.  But  his 
researches  were  confined  to  the  examination  of  the  jaws  after 
birth,  at  which  period  he  speaks  of  having  discovered,  by  dis- 
section, the  incisors,  cuspids  and.  three  molars  on  each  side,  in 
each  jaw,  partly  in  a  gelatinous  and  partly  in  a  solidified  con- 
dition. He  also  discovered  the  incisors  and  cuspids  of  the  per- 
manent set  behind  the  first. 

Eustachius  wrote  in  1563,  and  nineteen  years  later,  Urbian 
Hemard,  a  French  anatomist  and  surgeon,  although  unac- 
quainted with  the  work  of  the  former,  gave  a  very  similar  de- 
scription of  the  situation  of  the  crowns  of  the  incisors  and 
cuspids  of  both  sets  in  the  jaws  of  an  infant  at  birth.  He 
represents  them  as  partly  bony  and  partly  mucilaginous.  He 
also  discovered  the  bicuspids,  but  he  was  unable  to  find  the 
molars  at  so  early  a  period  as  at  birth. 

The  researches  of  Albinus  threw  no  additional  light  upon 
the  manner  of  the  formation  of  the  teeth,  and  little  was  known 
concerning  the  earlier  stages  of  the  development  of  these  organs 
until  the  time  of  John  Hunter,  who  informs  us  that  in  the 
alveoli  of  a  foetus  of  three  or  four  months,  "  four  or  five  pulpy 
substances,  not  very  distinct,  arc  seen."  But  he  says,  "  about 
the  fifth  month  the  alveolar  cavities  are  more  perfect  and  the 
pulps  of  the  teeth  more  distinct,"  and  that  the  anterior  are  more 
advanced  than  those  further  back  in  the  jaws.  It  is  at  about 
this  age  that  he  dates  the  commencement  of  dentinification  on 
the  edge  of  the  temporary  incisors.  The  situation  and  arrange- 
ment of  the  teeth  in  the  jaws  at  this  period  he  describes  very 
accurately.  At  the  expiration  of  the  sixth  or  seventh  month, 
he  represents  the  first  permanent  molar,  as  having  begun  to  be 
formed  in  the  tubercle  of  the  upper  jaw,  and  "  under  and  on 


100  ORIGIN    AND    FORMATION    OF    THE    TEETH. 

the  inside  of  the  coronoid  process  of  the  lower;"  and  he  states, 
that  the  pulps  of  the  permanent  central  incisors  begin  to  appear 
in  a  foetus  of  "seven  or  eight  months,"  and  to  dentinify  "five 
or  six  months  after  birth."  The  pulps  of  the  permanent  lateral 
incisors  and  cuspids  he  says  begin  to  be  formed  soon  after 
birth ;  the  first  bicuspids  about  the  fifth  or  sixth  year,  the 
second  bicuspids  and  molars  the  sixth  or  seventh,  and  the  dentes 
sapientiae  about  the  twelfth  year. 

Although  Mr.  Hunter  gives  a  more  minute  and  accurate  de- 
scription of  the  progress  of  the  formation  and  arrangement  of 
the  teeth  in  the  jaws  previously  to  their  eruption  than  any 
previous  writer ;  yet  with  regard  to  their  origin  and  appearance 
during  the  earlier  stages  of  their  develojiment  he  is  unsatis- 
factory. Nor  do  the  researches  of  Jourdain,  Blake,  Fox,  Cuvier, 
Serres,  Delabarre  and  other  writers,  throw  much  additional 
light  upon  the  subject.  In  fact,  they  could  not,  as  their  re- 
searches do  not  seem  to  have  been  commenced  at  periods 
suflBciently  early  in  foetal  subjects ;  and  even  from  the  time 
when  they  were  first  instituted,  the  progress  of  the  organs  does 
not  appear  to  have  been  traced  through  the  subsequent  stages  of 
their  formation  with  the  requisite  degree  of  care  and  accuracy. 
It  is  not,  therefore,  necessary  to  notice  the  description  given  by 
these  authors  of  the  progress  of  the  formation  of  the  teeth, 
although  it  may  not  be  amiss  to  state  here,  that  Dr.  Blake  de- 
scribes the  rudiments  of  the  permanent  teeth  as  originating  from 
the  sacs  of  the  temporary,  and  that  this  supposed  discovery  has 
been  confirmed  by  almost  every  subsequent  writer  upon  the  sub- 
ject.* Indeed,  until  quite  recently,  this  has  been  the  prevailing 
opinion,  and  their  progress,  step  by  step,  from  the  time  when 
the  rudiments  of  these  teeth  are  apparently  given  off  as  small 
bud-like  processes  from  the  sacs  of  the  temporary,  is  traced  with 
a  degree  of  minuteness  by  Mr.  Thomas  Bell  that  would  seem  to 
preclude  the  possibility  of  deception.  This  last  named  gentle- 
man describes  the  process  as  commencing  at  a  very  early  period 
of  the  formation  of  the  temporary  teeth,  and  as  first  perceivable 
"in  a  small  thickening  on  one  side  of  the   parent  sac,"  which, 

*  It  is  said,  but  with  how  much  truth  the  author  is  unable  to  say,  that  this  sup- 
posed discovery  was  made  about  twenty  years  before  the  publication  of  Dr.  Blake's 
Inaugural  Dissertation,  by  a  French  dentist  by  the  name  of  Herbert. 


ORIGIN    AND    FORMATION    OF    THE    TEETH.  101 

"  gradually  increasing,"  becomes  "  more  and  more  circumscribed; 
until  it  at  length  assumes  a  distinct  form,  though  still  connected 
with  it  bj  a  peduncle,  which,"  he  says,  "  is  nothing  more  than  a 
process  of  the  investing  sac."  "For  a  time,"  continues  Mr. 
Bell,  "  the  new  rudiment  is  contained  within  the  same  alveolus 
with  its  parent,  which  is  excavated  by  the  absorbents  for  its  re- 
ception, by  a  process  almost  unparalleled  in  the  annals  of 
physiology.  It  is  not  produced  by  the  pressure  of  the  new 
rudiment,  as  is  erroneously  believed,  but  commences  in  the  can- 
celli  of  the  new  bone,  immediately  within  its  smooth  surface,  thus 
constituting  what  may  be  termed  a  process  of  anticipation. 
The  new  cell,  after  being  sufficiently  excavated,  and  as  the 
rudiment  continues  to  increase,  is  gradually  separated  from  the 
former  one  by  being  more  and  more  deeply  excavated  in  the 
substance  of  the  bone,  and  also  by  the  deposition  of  a  bony 
partition  between  them ;  and  at  length  the  new  rudiment  is  shut 
up  in  its  proper  socket,  though  still  connected  with  the  tempo- 
rary tooth  by  a  cord  or  process  of  the  capsule  already  described, 
which  has  in  the  meantime  been  gradually  attenuated  and  elon- 
gated."* 

Now  it  would  hardly  seem  possible  for  a  man  of  Mr.  Bell's 
accuracy  of  observation,  after  having  investigated  the  subject  as 
closely  and  thoroughly  as  he  must  have  done,  to  have  enabled 
him  to  describe  so  minutely  the  various  stages  of  the  progress 
of  the  development  of  the  permanent  teeth,  to  have  mistaken 
their  origin ;  yet  that  he  has  would  appear,  by  subsequent  re- 
searches, to  be  rendered  certain.  I  allude  to  those  of  Arnold 
and  GooDSiR. 

The  last  named  author  has  traced  the  progress  of  the  teeth, 
almost  from  the  moment  of  the  appearance  of  the  germs  of  the 
first  set,  as  simple  mucous  papillae,  until  the  completion  of  those 
of  the  second;  and  so  minutely  and  accurately,  that  little  re- 
mains to  be  done  by  future  anatomists  for  the  perfection  of  this 
branch  of  odontology. 

*  This  cord  has  been  noticed  and  minutely  described  by  several  other  writers. 
Delabarre  calls  it  the  appendage  of  the  dental  matrix,  and  traces  it  through  what  is 
usually  denominated  the  alveolo-dental  canal,  which  he  designates  by  the  name  of 
iter  dentis,  to  the  svirface  of  the  gum  behind  the  temporary  teeth.  He  also  states  that 
it  is  hollow,  and  when  he  first  described  it  in  his  thesis  of  reception  in  1806,  it  had 
not  been  noticed  by  any  other  writer. 


102 


ORIGIN    AND    FORMATION    OF    THE    TEETH. 


Relying  upon  the  accuracy  of  his  researches,  which  are  de- 
scribed, at  length,  in  the  Edinburgh  Medical  and  Surgical  Journal 
for  January  1st,  18-39,  we  shall  proceed  to  give  a  brief  summary 
of  their  result,  as  the  length  of  the  paper  is  such  as  to  preclude 
its  insertion  entire. 

His  investigations  were  commenced  in  an  embryo  at  the  sixth 
p  week,  at  which  period  a  deep  groove, 

formed  by  two  semi-circular  folds,  ex- 
tending around  each  jaw,  may  be  per- 
ceived, lined  with  mucous  membrane, 
and  as  this  gradually  widens  from  behind 
forwards,  a  ridge,  commencing  poste- 
riori}" and  running  in  the  same  direc- 
/.B^'af  iheT;.h^':eel?a"Tre     tiou,  riscs   from  its   floor,   and   divides 

lip;  6  Primitive  deatal  groove.  ^^^     original    grOOVC     iutO    tWO     OthcrS  ; 

the  outer  one  forming  the  duplicature  of  mucous  membrane  from 
the  inside  of  the  lip  to  the  outside  of  the  alveolar  process ;  the 
inner  one  constituting  what  may  be  very  properly  denominated 
the  primitive  dental  groove,  as  the  germs  of  the  teeth  appear 
in  it. 

The  inner  lip  of  the  inner  groove  is  formed  by  the  outer  edge 

of  a  semi-circular  lobe  which 
is  to  constitute  the  future 
palate.  By  the  seventh  week 
after  conception,  the  germ  of 
the  first  temporary  molar  in 
the  upper  jaw  may  be  seen  ' 
in  the  primitive  dental  groove, 
rising  up  from  the  mucous 
membrane  lining  its  floor 
in  the  form  of  a  simple  free 
granular  papilla,  of  an 
ovoidal  shape — the  long  dia- 

F.o.  4.-,.  Lower  jaws  ofhama„..,nhrvo  .,  .ho, „„,h  meter     of      which     is     aUtcrO- 

week  of  intra-uterine  life,  (from  Kiilliker  :)  magnified  r,nofprinr  T5v  thp  PlVhth  MtPfAc 
uine  diameters:  o  Tongue  thrown  back;  b  Right  pOSltriOr.  J:>y  XUt  ClgniU  W  eCK, 
half  of  the  lip  depressed  ;  6  Left  half  cut  off :  c  Outer  .1  •■\^  e  J      1 

alveolar  wall;  dinner  alveolar  wall,  «  Pa;j(7/a  of  another  papilla,  01  a  rOUndeCl 
the  first  molar;  /  Papilla  of  the  cuspid  ;  g  Of  the  ,  ^        c  •        i. 

second  incisor;  h  Of  the  first  incisor;  t  Folds  where  and  granular  lOrm,  IS  ODSCrV- 
tbe  (2t(c/t  iStviniani  subsequently  eater.  ^  ^       \  • -i  ■^^ 

able,  between  the  middle  and 
anterior  curve  of  the  ridge,  on  the  floor  of  the  same  groove. 


Fig.  45. 


\  c 


ORIGIN   AND    FORMATION    OF    THE   TEETH.  103 

which,  is  the  rudiment  of  the  temporary  cuspid.  During  the 
ninth  ■vveok,  the  germs  of  the  incisors — the  central  first,  and  soon 
after  the  lateral — make  their  appearance  in  the  form  also  of 
mucous  papillae.  During  the  tenth  week  the  sides  of  the  groove 
before  and  behind  the  anterior  molar  papilla  have  been  gradually 
approaching  each  other  and  processes  from  its  sides  are  sent  oif, 
from  before  and  behind  this  germ,  which  meet  and  enclose  it  in 
a  follicle.  In  the  meantime  a  similar  follicle  is  gradually  form- 
ing around  the  cuspid  germ.  Towards  the  end  of  the  tenth 
week,  the  papilla  of  the  second  or  posterior  temporary  molar 
shows  itself. 

The  papillae  of  the  incisor  teeth,  which,  up  to  this  time,  have 
advanced  very  slowly,  now  begin-  to  increase  more  rapidly ;  and 
during  the  eleventh  and  twelfth  weeks,  processes  are  sent  off 
from  the  outer  and  inner  walls  of  the  groove,  forming  for  each 
a  distinct  follicle,  and  while  the  papillae  of  the  cuspid  and 
first  molar  are  now  undergoing  little  change,  that  of  the  second 
molar  is  gradually  increasing.  During  the  thirteenth  week  a 
follicle  is  formed  for  it,  and  a  gradual  change  takes  place  in  the 
different  papillae  ;  each  begins  now  to  assume  a  particular  shape 
— the  incisors,  that  of  the  future  teeth — the  cuspids  "  become 
simple  cones," — the  molars  "  become  flattened  transversely."  The 
papillae  now  "grow  faster  than  the  follicles,  so  that  the  former 
protrude  from  the  mouths  of  the  latter,  while  the  depth  of  the 
latter  varies  directly  as  the  length  of  the  fangs  of  their  future 
corresponding  teeth."  The  mouths  of  the  follicles,  in  the  mean- 
time, are  becoming  more  developed,  "so  as  to  form  opercula  or 
lids,  which  correspond  in  some  measure  with  the  shape  of  the 
crowns  of  the  future  teeth."  Of  these,  the  incisor  follicles  have 
two — one  anterior  and  one  posterior — the  first  larger  than  the 
latter ;  the  cuspid  follicles  have  three — one  external  and  two 
internal ;  the  molar  follicles,  as  many  as  there  are  eminences  or 
tubercles  upon  the  grinding  surfaces  of  these  teeth. 

The  outer  and  inner  lips  of  the  primitive  dental  groove  have 
increased  so  much,  that  at  the  fourteenth  week,  they  meet  together 
like  two  valves,  so  as  to  give  the  papillae  the  appearance  of  re- 
ceding back  into  their  follicles,  and  to  become  almost  wholly 
hidden  by  their  opercula.  The  appearance  and  progress  of  the 
germs  of  the  lower  teeth  and  their  follicles  are  almost  precisely 


104  ORIGIN    AND    FORMATION    OF    THE    TEETH. 

similar  to  those  of  the  upper,  though  they  do  not  appear  at  quite 
so  early  a  period. 

At  the  epoch  last  mentioned,  the  primitive  dental  groove  in 
each  jaw  is  situated  on  a  higher  level  than  at  first,  contains  the 
germs  and  follicles  of  the  ten  temporary  teoth,  and  "  may  now 
be  more  properly  denominated  the  secondary  dental  groove,"  for 
it  is  about  this  time,  that  provision  is  made  for  the  production  of 
the  ten  anterior  permanent  teeth.  It  consists  in  the  appearance 
of  a  crescent  shaped  depression  immediately  behind  the  inner 
opercula  of  the  follicles  ;  first,  of  the  central  incisors,  next  of  the 
laterals,  then  of  the  cuspids,  afterwards  of  the  first  bicuspids. 
The  opercula,  in  the  meantime,  close  the  mouths  of  the  follicles, 
but  without  adhering  to  them  ;  beginning  with  the  central  in- 
cisors, then  continuing  with  the  lateral,  and  the  cuspids,  and 
ending  with  the  second  molars.  The  secondary  groove  is  now 
soon  closed  by  the  approach  and  adhesion  of  its  lips  and  walls, 
commencing  from  behind  and  proceeding  forward ;  changing 
the  follicles  or  pits  into  sacs,  the  papillae  into  the  pulps  of  the 
temporary  teeth,  and  the  crescent-formed  depressions  into  "  cavi- 
ties of  reserve'' iv  ova  which  the  pulps  and  sacs  of  the  teeth  of  re- 
placement are  developed.  The  jjrimitive  dental  groove,  which, 
by  this  time,  has  extended  back  of  the  second  temporary  molar, 
still  retains  its  original  appearance  ;  it  has  a  grayish  yellow 
color,  and  its  edges  continue  "  smooth  for  a  fortnight  or  three 
weeks  longer  "  for  the  development  of  the  papilla  and  follicle  " 
of  the  first  permanent  molar. 

The  papillae  of  the  temporary  teeth  are  now  gradually  moulded 
into  the  shape  of  the  dentine  of  the  crowns  of  the  teeth  they  are 
destined  to  form :  the  pulps  of  the  upper  molars  are  perforated 
by  three  canals,  and  the  lower  by  two,  which  penetrate  to  their 
centre.  The  primary  base  is  divided  into  an  equal  number  of 
secondary  bases,  from  which  the  roots  of  the  future  teeth  are  gra- 
dually to  be  developed.  An  intervening  space  is  now  formed 
between  the  pulps  and  the  sacs,  by  the  more  rapid  growth  of  the 
latter  than  the  former,  "  in  which  is  deposited  a  gelatinous  granu- 
lar substance,  at  first  small  in  quantity,  and  adherent  only  to 
the  proximal  surfaces  of  the  sacs,  but  ultimately,  about  the  fifth 
month,  closely  and  intimately  attached  to  the  whole  interior  of 
these  organs,  except  for  a  small  space  of  equal  breadth,  all  round 


ORIGIN    AND    FORMATION    OF    THE    TEETH.  105 

the  base  of  the  pulps,  which  space  retains  the  original  gray  color 
of  the  inner  membrane  of  the  follicle ;  and  as  the  primary  base 
of  the  pulp  becomes  perforated  by  the  canals  formerly  mentioned, 
the  granular  matter  sends  processes  into  them,  which,  adhering 
to  the  sac,  reserve  the  narrow  space  described  above,  between 
themselves  and  the  secondary  bases.  These  processes  of  granu- 
lar matter  do  not  meet  across  the  canals,  but  disappear  near 
their  point  of  junction."  The  granular  matter,  although  not  ad- 
hering to  the  pulp,  is  exactly  moulded  to  all  its  eminences  and 
depressions. 

The  outer  membrane  of  the  sac,  according  to  Mr.  Goodsir,  is 
supplied  with  blood  from  small  twigs  sent  off  by  each  branch  of 
the  dental  artery  at  the  fundus  of  its  destined  sac,  and  from  the 
arteries  of  the  gums,  which  inosculate  with  each  other,  and  then 
ramify  in  the  "true"  (inner)  membrane. 

The  follicle  of  the  first  permanent  molar  closes  about  this 
time,  and  has  granular  matter  deposited  in  its  sac,  and  by  the 
non-adhesion  of  the  walls  of  the  secondary  groove,  a  cavity  ap- 
pears below  the  sac  of  this  tooth ;  from  the  lining  mucous  mem- 
'  brane  of  which  the  second  molar  germ  originates,  and  from  the 
second  sac  a  new  offset  shoots  forth,  destined  to  contain  the 
papilla  of  the  dens  sapientice. 

But  previously  to  this  period,  the  apices  and  eminences  of  the 
temporary  teeth  have  become  vascular,  and  now  earthy  salts  be- 
gin to  be  deposited.  Simultaneously  with  this  process,  the_^inner 
surface  of  the  granular  matter  is  absorbed,  and  after  a  while  be- 
comes so  thin  as  to  render  the  subjacent  vascularity  apparent. 
This  continues  until,  by  the  time  a  layer  of  dentine  has  formed 
over  the  whole  surface  of  the  pulp  and  reached  its  base,  no 
remains  of  it  are  left. 

The  cavities  of  reserve  have  been  gradually  receding  and  as- 
suming a  position  behind  the  temporary  teeth  ;  the  distal  extremi- 
ties of  the  anterior  ones  begin  to  distend  about  the  fifth  month, 
and  it  is  here  that  the  germs  of  the  teeth  of  replacement  first 
appear,  and  are  indicated  by  a  bulging  up  or  folding  of  this  por- 
tion of  these  cavities.  These  soon  acquire  the  appearance  of 
dental  pulps,  and  the  mouths  of  the  cavities  gradually  become 
obliterated. 

By  the  sixth  month,  bony  septa  have  formed  across  the  alveo- 


106 


ORIGIN    AND    FORMATION    OF    THE    TEETH. 


lar  groove,  .'uid  niches  nre  now  formed  on  tlie  posterior  walls  of 
the  alveoli  for  the  sacs  of  the  permanent  teeth.  The  sac  of  the 
first  permanent  molar  remains  up  to  the  eighth,  and  even  the 
ninth  month,  imbedded  in  the  maxillary  tuberosity.  The  roots 
of  the  temporary  incisors,  at  or  a  little  before  birth,  begin  to  be 
formed;  in  the  accomplisliment  of  which,  says  Mr.  Goodsir, 
"  three  contemporaneous  actions  are  employed,  viz.  the  lengthen- 
ing of  the  pulp  ;  the  deposition  of  tooth  substance  upon  it ;  and 
the  adhesion  of  the  latter  to  that  portion  of  the  inner  sac  which 
is  opposite  to  it."  By  this  time  the  central  incisors  appear 
through  the  gum,  the  jaw  has  lengthened  so  much,  that  the  first 
permanent  molar  begins  to  assume  its  proper  position  in  the  pos- 
terior part  of  the  alveolar  arch.  The  sacs  of  the  permanent 
teeth  continue  to  recede  during  the  advance  of  the  temporary 
teeth  and  their  sockets  to  acquire  their  perfect  state,  and  to  in- 
sinuate themselves  between  the  sacs  of  the  former  until  they  are 
connected  by  their  proximal  extremities  only,  through  the  alveolo- 
dental  foramina  or  itinera  dentium  of  Delabarre. 


Fig.  46. 


Fio.  46.  a  Mncous  membrane;  6  Mucons  membrane,  with  a  granular  mass  deposited  in  it; 
c  The  primitive  dental  groove  ;  d  A  papilla  on  the  floor  of  the  groove  ;  e  The  papilla  enclosed  in  a 
follicle,  and  the  secondary  denial  groove  forming  ;  /  The  pHi'ilU  assuming  the  shape  of  a  pulp, 
the  operciila  forming,  and  a  depression  for  a  reserve  caviiy  behind  the  inner  operculum  ;  g  The 
papilla  becomes  a  pulp,  and  the  follicle  a  sac  by  the  adliesion  of  the  lips  of  the  opercula  ;  the 
secondary  deutal  groove  in  the  act  of  closing  ;  h  The  secondary  groove  adherent,  except  behind 
the  inner  operculum,  where  it  has  left  a  shut  cavity  of  reserve  for  the  formation  of  the  pulp  and 
eac  of  the  permanent  tooth  ;  i  The  last  change  more  complete  by  the  deposition  of  the  granular 
body,  deposition  of  tooth  substance  commencing  :  j  The  caviiy  of  reserve  receding ;  its  bottom,  in 
which  the  pulp  is  forming,  dilating;  k  The  cavity  of  reserve  becoming  a  sac  wiih  a  pulp  at  its 
bottom,  and  further  removed  from  ihe  surface  of  the  gums.  The  temporary  tooth  covered  with 
a  layer  of  bone,  and  the  granular  substance  absorbed  ;  I  The  tempurary  tooth  acquiring  its  root 
and  approaching  the  surface  of  the  gums;  m  Root  of  the  temporary  tooth  longer,  and  its  sac 
touching  the  surface  of  the  gum  ;  n  Eruption  of  temporary  tooih,  it-  sac  again  a  follicle,  and  the 
permanent  receding  further  from  Ihe  surface  of  the  I'um  ;  o  (  ompletion  of  temporary  tooth,  free 
portion  of  sac  become  the  vascular  margin  of  the  gum.  and  the  permanent  sac  connected  by  a 
cord  passing  through  the  alveolo-dental  canal  or  foramen. 

The  vessels  which  go  to  the  sacs  of  the  permanent  teeth  are 
derived,  first,  from  the  gums,  but  they  ultimately  receive  vessels 


ORIGIN    AND    FORMATION    OF    THE    TEETH. 


107 


from  the  temporary  sacs,  which,  uniting  with  the  others,  even- 
tually retire  into  permanent  dental  canals. 

The  foregoing  diagram,  taken  from  Goodsir,  exhibits  at  one 
view  the  origin  and  progress  of  the  formation  of  a  temporary 
and  its  corresponding  permanent  tooth. 

The  cavity  of  reserve,  behind  the  first  permanent  molar, 
begins  to  lengthen  about  the  seventh  or  eighth  month ;  a  papilla 
soon  appears  in  its  fundus,  it  then  contracts  and  separates  from 
the  remainder  of  the  cavity,  by  which  means  a  new  sac  is  formed — 
that  of  the  second  permanent  molar.  As  the  jaw  increases  in 
length,  it  comes  downward  and  forward.  The  papillae  of  the 
wisdom  teeth  (dentes  sapientise)  form  in  the  remaining  portion 
of  the  cavities  of  reserve,  which,  in  the  upper  jaw,  occupy  the 
maxillary  tuberosities,  and  in  the  lower,  the  base  of  the  coronoid 
processes,  which  places,  says  Goodsir,  they  do  not  leave  until 
the  nineteenth  or  twentieth  year. 

The  progress  of  the  formation  of  the  three  molar  teeth  will 
be  seen  in  the  diagram.  Fig.  47,  also  copied  from  Mr.  Goodsir. 

Fig.  47. 


T 


1 


rxx) 

FiQ.  47.  a  The  non-adherent  portion  of  the  primitive  dental  groove  ;  b  The  papilla  and  follicle 
of  the  first  molar  on  the  floor  of  the  nonadherent  portion,  now  become  a  portion  of  the  secondary 
groove  ;  c  The  papilla  a  pulp,  and  the  follicle  a  sac,  and  the  lips  of  the  secondary  groove  adhering, 
80  that  the  latter  has  become  the  posterior  or  great  cavity  of  reserve  ;  d  The  sac  m('  the  first  molar 
increased  in  size,  advancing  into  the  coronoid  process  or  maxillary  tuberosity,  and  the  cavity  of 
reserve  lengthened  ;  e  The  sac  of  the  first  molar  returned  by  the  same  path  to  its  former  position, 
and  the  cavity  of  reserve  shortened  ;  /  The  cavityof  reserve  sending  backward  the  sac  of  the 
second  molar ;  g  The  sac  of  the  second  molar  advanced  into  the  coronoid  process  or  the  maxillary 
tnborosity ;  h  The  second  molar  sac  returned,  and  the  cavity  of  reserve  shortened  ;  i  The  cavity 
of  reserve  sending  oil  the  sac  and  pulp  of  the  wisdom  tooth;  ,/  The  sac  of  the  wisdom  tooth  ad- 
vanced into  the  coronoid  process  or  maxillary  tuberosity  ;  k  The  sac  of  the  wisdom  tooth  returned 
to  the  extremity  of  the  dental  range. 


108  FORMATION    OF   THE    DENTINE. 

From  the  foregoing  abridgement  of  the  description  given  by 
Mr.  Goodsir  of  the  development  of  the  pulps  and  sacs  of  the 
human  teeth,  it  is  seen,  that  the  papilla  of  the  first  temporary 
molar  makes  its  appearance  at  about  the  seventh  week  of  em- 
bryonic life;  at  the  eighth  week,  the  cuspid  papilla  is  developed; 
during  the  ninth,  the  papillce  of  the  incisors  make  their  appear- 
ance, and  by  the  end  of  the  tenth  week,  the  papilla  of  the  second 
temporary  molar  may  be  seen.  At  the  end  of  the  fourteenth 
"week,  the  upper  part  of  the  primitive  dental  groove,  containing 
the  germs  and  follicles  of  the  ten  temporary  teeth,  becomes  the 
secondary  dental  groove,  from  which  the  papillae  of  the  teeth  of 
replacement  are  furnished.  The  secondary  groove  assumes  the 
form  of  crescent-shaped  depressions  behind  the  palatine  oper- 
cula  of  the  follicles  of  the  temporary  teeth.  The  cavities  of 
reserve  for  the  permanent  teeth  gradually  recede,  and  assume  a 
position  behind  the  sacs  of  the  deciduous  teeth,  and  from  the 
distal  extremities  of  these  the  papilla;  of  the  replacing  teeth  are 
developed. 

FORMATION  OF  THE  DENTINE. 

With  regard  to  the  manner  of  the  formation  of  the  dentine, 
odontologists  do  not  agree.  Mr.  Thomas  Bell  is  of  the  opinion 
that  it  is  secreted  by  the  external  surface  of  a  membrane  which 
immediately  invests  the  pulp,  designated  by  Raschkow  the  p7'e- 
formative  membrane,  the  pulp  serving  only  as  a  mould  upon 
which  this  substance  is  formed.  Purkinjtj  and  Schwann  believe 
that  the  pulp  is  converted  into  dentine  by  a  transition  process, 
the  superficial  cells  upon  the  surface  assuming,  first,  an  elongated 
form,  corresponding  in  diameter  and  direction  with  the  fibres  of 
the  dentine;  or,  in  other  words,  that  the  dentine  is  formed  by 
the  dentinification  of  the  pulp. 

Professor  Owen  maintains  that  it  is  by  ^^centripetal  calcifica- 
tion of  the  pulp's  substance."  He  sayg,  "  In  the  cells  of  the 
dentinal  pulp  the  nucleus  fills  the  parent  cell  with  a  progeny  of 
nucleoli  before  the  work  of  calcification  (or,  more  properly,  of 
dentinification)  begins."  Again,  "The  primary  cells  and  the 
capillary  vessels  and  nerves  are  imbedded  in  a  homogeneous, 
minutely  subgranular,  mucilaginous  substance.     The  cells,  which 


FORMATION    OF   THE    DENTINE.  109 

are  smallest  at  the  base  of  the  pulp,  and  have  large,  simple, 
subgranular  nuclei,  soon  fall  into  linear  series,  directed  towards 
the  periphery  of  the  pulp:  where  the  cells  are  in  close  proximity 
with  that  periphery,  they  become  more  closely  aprgregated,  in- 
crease in  size,  and  present  the  following  changes  in  their  interior — 
A  pellucid  point  appears  in  the  centre  of  the  nucleus,  which  in- 
creases in  size  and  becomes  more  opaque  around  the  central 
point,  rendering  the  compressorium  requisite  for  its  demonstra- 
tion. A  division  of  the  nucleus  in  the  course  of  its  long  axis 
is  next  observed.  In  the  larger  and  more  elongated  cells,  still 
nearer  the  periphery  of  the  pulp,  a  subdivision  of  the  nuclei  has 
taken  place,  and  the  subdivisions  become  elongated  with  their 
long  axis  vertical  or  nearly  so  to  the  plane  of  the  pulp,  and  to 
the  field  of  calcification.  The  subdivided  and  elongated  nuclei 
become  attached  hy  their  extremities  to  the  corresponding  nuclei 
of  the  cells  in  advance;  and  the  attached  extremities  become 
confluent.  Whilst  these  changes  are  in  progress,  the  calcareous 
salts  of  the  surrounding  plasma  begin  to  be  accumulated  in  the 
interior  of  the  cells,  and  to  be  aggregated  in  a  semi-transparent 
state  around  the  central  granular  part  of  the  elongated  nuclei, 
which  now  present  the  character  of  secondary  cells,  and  the  salts 
occupy,  in  a  still  clearer  and  more  compact  state,  the  interspaces 
of  such  cells;  the  elongated  granular  matter  of  the  terminally 
confluent  secondary  cells  establishes  the  area  of  the  tubes,  by 
resistinor,  as  it  would  seem,  the  encroachment  of  the  calcareous 
salts;  the  nuclear  tracts  receiving  a  similar  proportion  of  the 
salts,  in  the  condition  of  minute  disintegrated  particles,  which 
are  usually  arranged  in  a  linear  series  of  nodules,  and  contribute 
to  cause  the  white  color  of  the  moniliform  area  of  the  tube, 
when  viewed  by  reflected  light,  and  its  opacity  when  viewed  by 
transmitted  light.  Thus  the  primitive  existence  of  the  granular 
nuclei,  their  multiplication  in  the  primary  or  parent  cell,  their 
elongated  form,  their  serial  arrangement  end  to  end,  and  termi- 
nal confluence,  are  indicated  in  the  calcified  pulp  by  the  area  of 
the  dentinal  tubes ;  the  interspaces  of  the  metamorphosed  nuclei 
being  occupied  by  calcareous  salts  in  a  clearer  and  more  compact 
state ;  with  evidence,  however,  of  a  distinctness  of  the  nucleolar 
membrane,  or  secondary  cell  from  the  cavity  of  the  common 
containing  cell,  which  sustains  the  interpretation  of  the  proper 


110 


FORMATION    OF   THE    DENTINE. 


Fig.  48. 


parietes  of  the  dentinal  tube.  The  indications  of  the  primitive 
boundary  or  proper  parietes  of  the  parent  cell  are  in  like  man- 
ner more  or  less  di.stinctlj  retained,  through  a  modification  of 
the  arrangement  of  the  calcareous  salts  in  the  boundaries  and 
in  the  interspaces  of  the  cells."  The  foregoing  is  but  a  small 
part  of  the  description  given  by  this  learned  writer,  but  enough 
to  show  his  views  upon  this  intricate  operation  of  the  economy, 
Mr.  Alexander  Nasmyth  says,  "  The  cells  of  the  pulp  are 
converted   into  ivory"    (or   dentinal)   "cells   by   the   deposition 

within  them  of  earthy 
salts,  and  the  cells  so 
converted,  with  their  nu- 
clei, are  the  perfect 
Vi^  ivory ;  moreover,  the 
nuclei  assume  a  peculiar 
arrangement  and  consti- 
tute the  structure  which 
I  have  described  and  de- 
monstrated by  the  name 
of baccated fibres."  This 
explanation  of  the  man- 
ner of  the  formation  of 
dentine,  designated  by 
^Ir.  Nasmyth  by  the 
name  of  ivory,  differs 
from  that  given  by  Pro- 
F.n  js;  i  Hi..„r»„, i.^  (      X,   Tvr       .u.       V      fessor   Owen  in  respect 

t  lo.  4,s  A  diagram  copied  from  Mr.  Nasmylh  s  work  on  r 
the  Development,  Structure  and  r)i.seasps  of  the  Teeth,  show-  nf  fVi<»  nnrt  tnlron  in  tli*>. 
ing  the  va>cular  and  cellular  structure  of  the  pulp  of  a  ^  V  L^ft-ti"  iU  tilt- 
tooth,  and  the  conversion  of  the  cells  into  dentine,  a  "The  ,-,,.„„o„„  k-ir  tV.o  T111/.I0;  ^f 
bloid-vessels  and  capillaries  of  the  pulp,  between  which  the  r^"*^*^**  "j  ^"^  llUCiei  Ol 
cellular  structure  is  seen."  6  "  The  cells  in  proce-s  of  con-  .  1  A  *■'  11  1  I' 
version  into  ivory."  or  dentine,  "and  occupying  the  peri-  tUe  (iCntine  CCllS,  and  01 
pheral  portion  of  the  pulp."  "  In  the  line  between  c  c,  the  1  c  \.  ^ 
tran.sition  of  the.se  celLs  into  the  structure  of  ivory,"  or  den-  the  UaturC  Ot  the  rCSUlt- 
tine,  Is  more  clearly  exhibited.  .               .                      1  •    1 

ant  ivory  itself;  which, 
according  to  Owen,  to  many  of  his  predecessors  and  to  the 
most  autlioritative  among  his  contemporaries,  is  permeated  by 
an  infinity  of  anastomosing  canaliculi,  while  the  tubules,  more 
or  less  marked  by  constiictions,  are  recognized  by  Nasmyth  as 
solid  fibres. 

The  changes  which  the  pulp  undergoes  a  little  before  and  at 
about  the  time  of  the  commencement  of  the  deposition  of  earthy 


FORMATION    OF    THE    DENTINE. 


Ill 


Fig.  49. 


Fig.  50. 


^i^^vJ^ 


salts  is  described  more  clearly  by  Mr.  Tomes  than  by  any  pre- 
ceding writer.  He  divides  the  development  of  the  pulp  into 
three  stages.  The  first,  he  terms  the  areolar ;  the  second,  the 
cellular^  and  the  third,  the  linear  stage.  The  first  embraces  the 
period  of  the  earliest  appearance  of  the  pulp;  the  second,  from 
the  time  when  it  is  composed  of  nucleated  cells  and  a  subgranular 
uniting  medium,  to  the  period  when  the  former  begins  to  assume 
a  linear  arrangement ;  which  arrangement  immediately  precedes 
dentinification,  and  constitutes  the  third  stage.  The  cells  nearest 
to  the  coronal  surfaces 
are  the  first  to  assume 
this  position.  The  col- 
umns thus  formed  of 
the  cells  take  an  ar- 
rangement nearly  ver- 
tical to  the  coronal  sur- 
face, or  corresponding 
to  the  direction  of  the 
dentinal  tubes  or  fibres 
of  the  perfected  tooth,    ^     ,„  ^i,      ,  .   .  ,  ^  r     ,   .  j 

^  '      Fia.  49.  The  pulp  m  Us  second  stage  composed  of  nucleated 

and  running  parallel  to  •'«i'-^»?-'''J;'P^'''','^'.'''^T''-    ,        ,   ,  ,^    .^ri  «.,.p 

o  r  Fio.  oO.  The  pulp   in   the  early   part  of  the   third   stage, 

each     Othpr  C!pjj|.ppl^  showing  the  cells  arranged  in  lines.    Copied  from  Mr.  Tomes. 

any  trace  of  the  areolar  tissue  seen  in  the  first  or  earlier  stage 
can  be  detected  in  this,  the  second  stage. 

These  three  conditions,  in  the  advanced  pulp,  are  not  distin- 
guished, according  to  Mr.  Tomes,  by  well  defined  lines  of  demar- 
cation, "  but  are  beautifully  blended,  the  one  with  the  other, 
passing  from  the  one  extreme  of  condition  to  the  other  so  grad- 
uallj'  that  the  transitions  are  not  at  first  recognized,  and  when 
fully  recognized  are  again  lost  in  the  gradations  towards  a  fur- 
ther chanofe." 

o 

The  cells  decrease  in  size  from  the  surface  toward  the  central 
portion  of  the  pulp;  but  the  smaller  increase  to  the  size  of  the 
larger  when  the  time  for  their  dentinification  arrives.  Each  cell 
after  falling  into  line,  divides  lengthwise  into  two  or  more,  and 
each  division  elongates.  A  central  nucleus  or  open  space  is 
seen  in  eabh  cell,  which  lengthens  with  the  cell.  The  cells  by 
their  increased  length  become  placed  end  to  end,  and  ultimately 
unite;  and  the  elongated  central  space  of  each  individual,  by  a 


112 


FORMATION    OF    THE    DENTINE. 


further   development,  joins   with   and   opens  into   those   of  the 
super-imposed  cells;   thus  forming  a  central  tube  common  to  the 
linearly  united  cells,"  as  seen  in  Fig.  51.      "At  or  a  little  be- 
FiG.  51.  fore  this  period  of  development  the 

earthy  matter  is  received  into  the  cel- 
lular or  rather  tubular  and  intertu- 
bular  tissue,  whereby  the  gelatinous 
matrix,  having  assumed  the  required 
form,  is  converted  into  tubular  and 
intertubular  tissue ;  in  other  words 
into  dentine.  In  some  instances  the 
linearly  arranged  cells  have  two  or 

Fiu.  51.    The  pulp  in   the  third   stage,  ^i  ^       ,  •    •  i.     ^    • 

showing  the  cells  placed  end  to  end  and  CVCU  thrCC  Central  CaVltlCS,  DUt  in 
becoming  confluent ;  also,  two  lines  of  cells  /»      i  i  i 

aniting  to  form  one.  the   progrcss  01    development  they 

become  joined  in  one.  Sometimes  they  appear  empty,  at  other 
times  occupied  by  granular  matter.  In  either  case  they  are 
usually  described  under  the  name  of  nuclei."  The  transparent 
structureless  membrane  enclosing  the  pulp  is  the  first  to  undergo 
solidification. 

Professor  Kiilliker  entertains  very  nearly  the  same  opinion 
with  regard  to  the  manner  of  the  formation  of  dentine  as  that 
expressed  by  Mr.  Tomes.  After  advancing  three  hypotheses, 
he  concludes  by  expressing  the  belief,  that  the  matrix  of  the 
dentinal  tubes,  the  intertubular  tissue,  "proceeds  from  the  cylin- 
drical cells  investing  the  pulp  of  the  tooth,  which  undergo  a 
greater  or  less  elongation,  coalesce  and  ossify."  The  canaliculi, 
or  tubes,  he  believes,  either  arise  from  the  nuclei  of  these  cells, 
or,  which  he  believes  to  be  more  probable,  are  the  remains  of  the 
cavities  of  the  cells,  the  boundaries  having  undergone  greater 
consolidation,  and  which,  therefore,  correspond  with  lacunae  of 
bone.  The  divisions,  he  thinks,  may  be  owing  to  a  longitudinal 
division,  from  time  to  time,  of  the  cells,  or  by  the  union  of  one 
cell  Avith  two  others. 

The  foregoing  brief  summary  of  the  opinions  of  the  authors 
referred  to,  will  serve  to  convey  an  idea  of  the  views  at  present 
entertained  with  regard  to  the  manner  of  the  formation  of  den- 
tine. 


I 


FORMATION    OF   THE    ENAMEL.  113 


F0R3IATI0N  OF  THE   EXAMEL  OF  THE  TEETH. 

The  opinion  formerly  entertained  upon  this  subject  was,  that 
the  enamel  is  a  deposition  from  the  inner  membrane  of  the  den- 
tal sac ;  that  this,  after  the  surface  of  the  pulp  of  the  tooth  has 
become  dentinified,  pours  out  upon  the  latter  a  thick  fluid,  "which 
soon  condenses,  assuming  at  first  a  chalky  appearance,  and, 
afterwards,  by  a  process  somewhat  similar  to  crystallization,  at- 
tains the  glossy-like  hardness  by  which  it  is  characterized.  Re- 
cent observations,  however,  especially  those  of  Raschkow,  es- 
tablish the  erroneousness  of  the  views  prevailing  among  older 
writers. 

The  gelatinous  granular  substance  mentioned  by  Goodsir, 
and  called  by  Raschkow  the  adamantine  organ,  situated  between 
the  follicle  and  tooth  germ,  (the  latter  of  which  it  invests,  at 
first  loosely,  but  afterwards  more  closely,  moulding  itself  to  the 
pulp,)  there  is  good  reason  to  believe,  is  destined  for  the  forma- 
tion of  the  enamel.  It  is  represented  by  the  last  named  author 
as  forming  a  globular  nucleus  between  the  follicle  and  dental 
germ  at  a  very  early  period  of  the  growth  of  the  latter,  with  a 
bulging  externally,  and  presenting  a  parenchymatous  appear- 
ance internally  ;  but  gradually  exhibiting  angular  granulations, 
held  together  by  filaments  of  areolar  tissue,  resembling  "  a  kind 
of  actinenchyma,  such  as  may  be  seen  in  plants."  It  was  the 
discovery  of  this  granular  substance  in  dissecting  the  jaws  of  a 
pig  that  first  induced  the  writer  to  suppose  the  old  doctrine  of 
the  formation  of  the  enamel  to  be  incorrect.  It  is  at  first  as  re- 
presented by  Raschkow  and  Goodsir,  disconnected  from  the  den- 
tal germ,  surrounded  by  fluid,  bearing  a  striking  resemblance  to 
the  lif|uor  amnii ;  but  is  gradually  transformed  into  a  membrane, 
and  as  dentinification  commences  in  the  pulp,  attaches  itself  to 
it,  and  adheres  with  considerable  tenacity. 

It  was  no  doubt  the  discovery  of  this  that  led  Delabarre  to 
suppose  the  enamel  an  integral  part  of  the  tooth  and  proceeding 
from  the  dental  embryo,  for  he  speaks  of  the  formation  of  this 
outer  coating  of  the  teeth  as  being  produced  by  an  immense 
number  of  small  exhalant  vessels  which  form  a  sort  of  imper- 
ceptible velvet.     Into  these  he  believed  the  phosphate  of  lime 


114  FORMATION  OF  THE  ENAMEL. 

was  deposited,  and  in  such  a  way  as  not  to  destroy  their  organic 
sensibility. 

Raschkow  says,  "  The  dental  germ,  in  advancing  further  and 
further  into  the  dental  follicle,  makes  first  only  a  slight  impres- 
sion on  tlie  globular  mass  of  the  enamel  organ,  but  this  impress 
is  rendered  gradually  deeper  as  the  growth  of  the  germ  proceeds. 
When  the  germ  has  penetrated  further  into  the  hollow  thus  made, 
it  appears  narrower  towards  the  base,  and  thicker  under  the 
apex,  and  is  enclosed  on  every  side  by  the  parenchyma  of  the 
enamel-organ,  which  thus  assumes  the  appearance  of  a  hood, 
covering  the  dental  germ  when  advanced  in  its  development, 
and  capable,  by  placing  it  under  water,  of  being  separated  from 
it  without  difficulty,  and  without  injury,  either  by  the  com- 
pressor, or  in  any  other  manner."  He  also  represents  it  as 
being  disconnected  from  the  dental  capsule,  except  at  the  coro- 
nal portion,  where  it  seems  to  be  united  by  some  loose  vessels ; 
it  is  thus  that  he  accounts  for  the  numerous  capillaries  which 
pervade  the  parenchyma  of  the  organ  ;  and  from  this,  he  as- 
sumes that  while  the  dental  germ  has  its  origin  from  the  ex- 
tremity of  the  sac  next  the  root,  the  enamel-organ  originates 
from  the  opposite  or  coronal  extremity,  and  that  "arising  at  op- 
posite points,  they  approach  each  other,  are  adapted  together, 
and  both  contribute  to  the  production  of  the  tooth." 

After  the  enamel-organ  has  adapted  itself  to  the  dental  pulp, 
a  peculiar  stratum  is  seen  on  its  inner  surface,  consisting  of  short 
uniform  fibres  placed  perpendicularly  "  to  the  cavity,  forming, 
as  it  were,  a  silky  lining"  to  it;  which,  in  a  transverse  section 
of  the  enamel-organ,  may  be  "  clearly  seen,  and  can  be  accu- 
rately distinguished  from  the  other  stellated  parenchyma  of  the 
substance,"  which  Raschkow  designates  the  enamel  pulp. 

According  to  this  author,  the  stratum  of  fibres,  originating 
in  "  the  transformation  of  the  pulp  of  the  enamel,"  with  which 
it  is  for  a  time  connected,  afterwards  separates  from  it,  so  as 
only  to  adhere  by  "  a  few  filaments  of  cellular  tissue,  and  be- 
comes a  genuine  membrane ;"  this,  on  account  of  the  function  it 
performs,  he  styles  the  enamel  membrane.  "  Its  inner  surface 
consists  of  hexangular,  nearly  uniform,  corpuscles,  visible  only 
through  a  magnifying  glass  ;  towards  the  centre  of  each  of  which 
is  a  round  eminence.     These  corpuscles  are  nothing  more  than 


FORMATION    OF    THE    ENAMEL.  115 

the  ends  of  short  fibres,  of  which  the  -whole  membrane  is  com- 
posed ;  and  which  being  pressed  together,  assume  freely  the  hex- 
angular  form."  These  he  describes  as  being  disposed  in  regular 
series,  and  corresponding  with  the  arrangement  of  the  enamel 
fibres. 

Each  of  these  fibres  is  an  excretory  duct  or  gland,  whose  pecu- 
liar function  it  is  to  secrete  the  "  enamel  fibre  corresponding  to 
it."  Immediately  after  the  commencement  of  dentinification  of 
the  pulp,  each  one  of  these  fibres,  with  its  inner  extremity  placed 
upon  the  now  forming  subjacent  dentine,  begins  to  secrete  the 
earthy  salts  of  which  this  substance  is  chiefly  composed.  While 
this  is  going  on,  an  organic  lymph  seems  to  be  secreted  from  the 
parenchyma  of  the  enamel-membrane  which  penetrates  between 
the  individual  fibres,  and  renders  their  whole  substance  soft. 
This,  by  means  of  a  "  chemico-organic  process,"  afterwards  com- 
bines with  the  earthy  substances,  and  forms  the  animal  base  of 
the  enamel. 

It  has  been  claimed  by  Raschkow,  that  the  dental  pulp  is  in- 
vested by  a  very  delicate  membrane,  which  he  denominates  the 
preformative  membrane  ;  and  there  is  every  reason  to  believe, 
that  this  constitutes  the  bond  of  union  between  the  enamel  fibres 
and  the  dentine  of  the  tooth. 

Admitting  this  theory  of  the  formation  of  the  enamel  to  be 
correct,  the  frame  work  of  animal  tissue,  spoken  of  by  Mr.  Na- 
smyth,  as  entering  into  the  composition  of  this  substance,  is 
readily  accounted  for.  In  no  other  way,  unless  the  theory  of 
Delabarre  be  correct,  and  this  is  b^^  far  the  most  plausible,  can 
its  presence  be  satisfactorily  explained. 

With  regard  to  the  manner  of  the  formation  of  NasmytKs 
membrane^  Professor  Kolliker  inclines  to  the  opinion  that  it  is 
"  a  calcified,  amorphous  exudation,  secreted  from  the  enamel 
organ  immediately  after  the  ossification  of  the  last  enamel  cells, 
which  glues  together  and  protects  the  ends  of  the  prisms  of  the 
enamel."  Huxley,  on  the  other  hand,  believing  the  enamel  to 
be  formed  beneath  the  membrane  which  invests  the  pulp,  called 
by  Raschkow  the  preformative  membrane,  is  of  opinion  that  Na- 
smyth's  membrane  is  merely  an  altered  condition  of  this.  His 
theory,  however,  of  the  manner  of  the  formation  of  the  enamel 
prisms,  as  well  as  of  the  membrane  in  question,  needs  confirma- 


116         FORMATION  OF  THE  CRUSTA  PETROSA. 

tion.     That  part  which  relates  to  the  formation  of  the  enamel 
fibres,  is  little  more  than  a  revival  of  the  theory  of  Delabarre. 


FORMATIOX  OF  THE  CEMEXTUM,  OR  CRUSTA  PETROSA. 

The  manner  of  the  formation  of  the  ceraentum,  has  been  vari- 
ously explained.  Raschkow  conjectures  that  it  is  probably  pro- 
duced by  the  remains  of  the  enamel  pulp.  More  recent  writers 
seem  to  regard  the  cemental  pulp  as  a  production  of  the  dental 
sac,  but  the  writer  is  inclined  to  believe  that  it  is  a  production 
of  that  portion  of  the  preformative  membrane  which  invests  the 
elongated  part  of  the  pulp  destined  for  the  formation  of  the  root ; 
and  that  this,  as  earthy  salts  are  deposited  in  the  pulp,  pours  out 
a  blastema  in  which  nucleated  cells  are  developed.  He  was  led 
to  the  adoption  of  this  belief  from  an  examination  of  a  tooth,  on 
every  part  of  the  surface  of  which,  there  is  a  development  of  ex- 
ostosis. Such  development  is  now  universally  admitted  to  be  a 
hypertrophied  condition  of  cementum,  the  structure  of  the  exos- 
tosis and  of  cementum  being  identical. 

The  tooth  in  question  belongs  to  the  Museum  of  the  Baltimore 
Dental  College,*  and  the  development  of  the  exostosis  must 
have  commenced  simultaneously  with  the  commencement  of  the 
deposition  of  earthy  salts  in  the  dentinal  pulp  ;  and  so  rapidly 
did  it  proceed,  that  it  completely  broke  up  the  enamel  organ, 
penetrating  every  part  of  it,  so  that  only  here  and  there,  im- 
bedded in  its  substance,  small  patches  of  enamel  are  seen.  This 
phenomenon  can  only  be  accounted  for  by  supposing  that  the 
investing  membrane  of  the  pulp,  from  some  inexplicable  cause, 
poured  out  a  blastema,  which  was  immediately  converted  into 
cementum,  and  that  this  took  on  a  hypertrophied  condition 
before,  or  simultaneously  with,  the  deposition  of  earthy  salts  in 
the  cells  of  the  fibres  of  the  enamel  organ. 

*  It  was  presented  to  the  Author,  for  this  institution,  by  Dr.  Swayze. 


CHAPTER     EIGHTH. 
FIRST   DENTITION. 

The  crowns  of  the  temporary  teeth,  as  has  been  shown,  are 
solidified  and  coated  with  enamel  at  birth,  and  although  at  about 
this  period  the  roots  of  the  incisors  begin  to  be  formed,  yet  the 
organs  still  occupy  their  bony  cells  in  the  alveolar  ridge.  But 
as  the  time  approaches  when  the  system  requires  a  diet  better 
suited  to  the  support  of  its  increasing  energies  than  milk,  the 
one  on  which  the  child  has  hitherto  subsisted,  nature,  as  if 
conscious  of  the  change  about  to  take  place,  calls  into  action 
certain  agents,  by  which  the  openings  into  the  alveolar  cells  are 
enlarged  ;  and  through  which,  in  obedience  to  an  established  law, 
the  little  gems,  sparkling  with  whiteness,  gradually  and  slowly 
emerge,  pair  after  pair,  until  the  pearly  arches  are  completed, 
to  answer  the  demands  of  increasing  wants,  and  to  assist  in  the 
articulation  of  those  lisping  accents  by  which  the  child's  early 
wishes  are  made  known. 

Dentition  is  divided  by  Mr.  Goodsir  into  three  stages,  namely, 
the  Follicular,  the  Sacular  and  the  Eruptive.  The  two  first 
have  already  been  considered,  and  it  now  only  remains  to  treat 
of  the  last. 

ERUPTION    OF    THE    TEMPORARY    TEETH. 

Various  opinions  have  been  advanced  with  regard  to  the 
manner  in  which  the  passage  of  a  tooth,  from  the  alveolus 
through  the  gum,  is  efiected.  Some  suppose  it  is  the  result  of 
the  elongation  of  the  pulp  for  the  formation  of  the  root;  others, 
that  it  is  a  consequence  of  the  moulding  of  the  alveolus  around 
the  latter,  as  it  is  formed.  Some  believe  that  the  opening  through 
the  gum  is  effected  by  the  mechanical  action  of  the  coronal  ex- 
tremity of  the  advancing  tooth ;  others,  and  with  far  more 
plausibility,  that  it  is  the  result  of  the  action  of  absorbent 
vessels  alone. 


118  ERUPTION    OF    THE    TEMPORARY   TEETH. 

The  able  physiologist  and  learned  dentist,  Delabarre,  has  ad- 
vanced a  most  ingenious  theory  upon  this  subject.  He  believes 
that  the  passage  of  a  tooth  through  the  gum,  or  rather  its  escape 
from  its  crypt,  is  effected  in  precisely  the  same  manner  as  is  the 
birth  of  a  child.  He  regards  the  sac,  attached  above  to  the 
gum  and  below  to  the  neck  of  the  tooth,  as  the  chief  agent  in 
the  eruption,  and  believes  that  it  is  by  its  contraction  that  the 
latter  is  raised  from  the  bottom  of  the  alveolus,  and  ultimately 
forced  through  the  dihited  orifice  of  the  capsule  and  gum. 

This  is  the  most  rational  theory  that  has  been  advanced ;  it 
explains,  upon  principles  of  sound  physiology,  this  most  wonder- 
ful and  curious  operation  of  the  economy.  It  is  difficult  to 
imagine  how  the  elongation  of  the  pulp,  or  the  moulding  of  the 
alveolar  walls  to  it,  can  have  any  agency  in  forcing  the  tooth 
through  the  gums.  If  the  elongation  of  the  pulp  commenced 
before  the  crown  of  the  tooth  had  made  any  advance  towards 
the  gums,  it  would  at  once  come  in  contact  with  the  floor  of  the 
alveolus,  and  in  its  soft  and  yielding  condition  be  caused  to 
assume  a  configuration  different  from  that  presented  by  the 
root  of  a  naturally  developed  tooth.  The  crown  of  the  tooth, 
therefore,  must  make  some  progress  towards  the  gum,  before  the 
elongation  of  its  pulp  can  commence,  and  it  is  difficult  to  con- 
ceive how  this  can  be  effected,  even  by  the  contraction  of  the 
sac,  unless  a  way  be  previously  or  contemporaneously  worked 
out  for  the  advancing  crown. 

This  theory  is  objected  to  by  some,  on  the  ground  that  the 
two  membranes  of  which  the  dental  matrix  or  sac  is  composed, 
are  of  a  fibrous  structure,  and  consequently,  not  endowed  with 
contractile  properties  ;  but  the  microscope  of  Mr.  Nasmyth  has 
shown  that  the  inner  lamina  is  composed  of  layers  of  cells,  loosely 
arranged,  and  separated  by  interspaces  equal  to  half  the  diame- 
ter of  the  cell.  In  another  place,  the  same  writer  observes,  that 
the  inner  lamina  seems  to  partake  more  of  the  nature  of  a  serous 
than  of  a  mucous  membrane.  That  the  sac  does  contract,  is 
proven  by  the  fact,  that  it  shortens  as  the  tooth  advances ;  so 
that,  ultimately,  after  the  complete  extrusion  of  the  crown,  it 
constitutes  the  free  edge  of  the  gum. 

The  dentinification  of  the  exterior  of  the  root  of  the  tooth  pro- 
ceeds nearly  as  fast  as  the  elongation  of  the  pulp  for  its  forma- 


ERUPTION  OF  THE  TEMPORARY  TEETH.         119 

tion.  Commencing  at  the  neck,  it  proceeds  inward  and  down- 
ward, forming  concentric  layers,  one  within  and  above  the 
other,  until  it  reaches  the  extremity  ;  until  nothing  remains  but 
a  small  canal  running  through  the  centre,  from  its  apex  to  the 
cavity  in  the  crown,  through  which  the  dental  vessels  and  nerves 
pass.  The  alveolus,  in  the  meantime,  deepens,  its  walls  ap- 
proach each  other,  and  closely  embrace  the  root  of  the  tooth. 

As  soon  as  the  edge  of  the  coronal  extremity  of  the  tooth  comes 
through  the  gum,  the  sac  resumes  its  primitive  follicular  condi- 
tion ;  but  still  connected  with  the  neck  of  the  tooth,  it  continues 
to  contract  until  the  whole  of  the  crown  has  emerged  from  the 
gum. 

The  periods  of  the  eruption  of  th«  temporary  teeth  are  variable, 
depending  probably  upon  the  state  of  the  constitutional  health. 
The  following,  however,  may  be  regard  as  a  very  near  approxi- 
mation, namely  : 

The  central  incisors  from  5  to  8  months  after  birth. 
"    lateral  incisors       "    7  to  10     "         "         " 
"    first  molars  "  12  to  16     "  "  " 

"    cuspids  "  14  to  20     "         "         " 

''    second  molars        "  20  to  36     "         "         " 

No  general  rule,  however,  can  be  laid  down  from  which  there 
will  not  be  frequent  deviations.  The  following  is  the  most  re- 
markable case  of  deviation,  not  only  from  the  normal  period, 
but  also  from  the  natural  order  of  the  eruption  of  the  teeth,  which 
the  author  has  ever  met  with.  In  November,  1846,  he  was  sent 
for  to  lance  the  gums  of  an  infant  only  four  months  old.  On  ex- 
amining the  mouth,  the  gums  on  each  side,  both  in  the  lower  and 
upper  jaws,  about  where  the  first  temporary  molars  are  situated, 
were  found  much  swollen  and  inflamed.  As  these  teeth  were 
evidently  forcing  their  way  through  the  gums,  and  as  the  child 
was  threatened  with  convulsions,  it  became  necessary  to  lance 
them  immediately.  This  was  accordingly  done,  to  the  instant 
relief  of  the  little  sufferer.  A  few  days  after,  the  teeth  made 
their  appearance,  but  the  eruption  of  the  central  incisors  did  not 
take  place  until  about  tlie  seventh  month. 

There  is  sometimes  an  extraordinary  tardiness  of  action  in 
the  eruption  of  the  temporary  teeth.  There  is  a  case  of  a  child, 
on  record,  that  did  not  cut  any  of  its  teeth  until  it  was  ten  years 


120         ERUPTION  OF  THE  TEMPORARY  TEETH. 

old.  Lefoulon  states  that  he  saw  a  young  girl,  seven  years  of 
age,  whose  inferior  incisors  had  not  yet  appeared.  Several 
cases  have  come  under  the  observation  of  the  author,  in  which 
dentition  did  not  commence  until  the  fifteenth,  and  in  one  not 
until  the  twentieth  month.  On  the  other  hand,  there  are  cases  of 
precocity  in  the  eruption  of  the  teeth  equally  remarkable,  as  for 
example,  when  the  two  lower  incisors  appear  at  birth ;  such  oc- 
currences have  been  met  with.  Louis  XIV.  was  born  with  four 
teeth,  and  Polydorus  Yirgilius  mentions  a  child  that  was  born 
with  six.  Haller,  in  his  Elements  of  Physiology,  enumerates 
the  cases  of  nineteen  children  who  were  born  with  teeth.  Other 
examples  are  on  record,  and  there  are  few  physicians  or  dentists 
who  have  been  in  practice  ten  or  fifteen  years,  who  have  not  met 
with  like  cases. 

In  speaking  of  those  early  productions,  Mr.  Fox  says,  "  As 
they  only  have  a  weak  attachment  to  the  gums,  they  soon  become 
loose,  producing  considerable  inflammation  in  the  mouth  of  the 
child,  as  well  as  occasioning  considerable  inconvenience  to  the 
mother.  It  is,  therefore,  advisable  to  extract  them  immediately, 
for  they  can  never  come  to  perfection."  The  author  is  compelled 
to  differ  with  Mr.  Fox,  for  their  attachment  is  not  always,  as  he 
supposes,  confined  to  the  gums  ;  their  roots  are  sometimes  secure- 
ly fixed  in  sockets  in  the  jaw.  When  this  is  the  case,  they 
seldom  occasion  much  inconvenience,  and  their  extraction  w'ould 
be  highly  improper.  It  is  always  better,  therefore,  to  wait  until 
there  is  some  positive  indication  that  such  operation  is  necessary, 
before  performing  it. 

In  the  eruption  of  the  teeth,  nearly  the  same  order  is  followed 
that  is  observed  in  their  solidification.  The  central  incisors  ap- 
pear first,  then  the  lateral,  next  the  first  molars,  afterwards  the 
cuspids,  and,  lastly,  the  second  molars. 

The  lower  teeth  in  their  eruption,  are  said,  usually,  to  precede 
the  upper  by  about  two  or  three  months,  but  the  upper  appear 
first  nearly  as  often  as  the  lower. 


I 


EFFECTS    OF    FIRST    DENTITION.  121 


MORBID  EFFECTS  RESULTING  FROM    FIRST  DENTITION. 

When  we  consider  the  early  age  at  which  first  dentition  com- 
mences, and  the  fragile  and  irritable  state  of  the  system,  it  will 
not  appear  wonderful  that  infants  should  so  frequently  suffer 
from  the  efforts  of  the  economy  for  the  liberation  of  these  organs 
from  the  bony  cells  and  superincumbent  gums,  in  which  they  are 
confined.  The  constitution,  at  this  tender  period  of  life,  often 
receives  a  shock  from  which  it  never  recovers ;  and  the  seeds  of 
many  chronic  diseases  are  caused  to  germinate,  which,  otherwise, 
in  all  probability,  would  have  forever  remained  dormant. 

This  is  generally  regarded  as  the  most  critical  period  of  life, 
and  it  has  often  proved  one  of  bereavement  and  sorrow.  The 
whole  process  is  sometimes  completed  without  inconvenience, 
but,  at  other  times,  it  is  attended  with  so  much  pain  and  irrita- 
tion that  the  most  alarming  and  complicated  forms  of  disease  re- 
sult from  it. 

The  irritation  accompanying  first  dentition  is  supposed  to 
be  caused  by  the  pressure  which  the  teeth  make  upon  the  gums 
in  forcing  their  way  out,  which  irritation  varies  in  extent,  ac- 
cording to  the  health  and  temperament  of  the  child.  When 
the  absorption  of  the  gums  and  dilatation  of  the  neck  of  the 
sac  keep  pace  with  the  growth  of  the  tooth,  the  pressure  is 
scarcely  perceptible ;  but  when  these  functions  are  tardily 
performed  it  becomes  more  or  less  great,  in  proportion  as  the 
growth  of  the  one  outstrips  the  absorption  and  dilatation  of  the 
other.  It  may  be,  that  much  of  the  irritation  is  produced  by 
the  pressure  of  the  tooth  upon  the  pulp ;  for,  when  its  progress 
is  retarded  by  the  resistance  of  the  gums,  the  elongation  of 
this,  for  the  formation  of  the  root,  would,  of  necessity,  cause  the 
solidified  part  to  press  upon  it ;  which  as  a  matter  of  course, 
would  give  rise  to  great  pain  and  irritation. 

Dr.  Good  is  of  opinion  that  the  pressure  of  the  teeth  against  the 
gums  "is  not  uniformly  exerted  throughout  the  course  of  teething, 
but  is  divided  into  distinct  periods  or  stages;  as  though  the  vital 
or  instinctive  principle,  which  is  what  we  mean  by  nature, 
becomes  exhausted  by  a  certain  extent  of  action,  and  requires 
rest  and  a  state  of  intermission. 
9 


122  EFFECTS    OF   FIRST   DENTITION. 

"  The  first  or  active  stage  of  teething  is  usually  about  the 
third  or  fourth  month  of  infancy,  and  constitutes  what  is  called 
breeding  the  teeth  ;  or  the  conversion  of  the  pulpy  rudiment 
buried  in  the  gums  and  formed  during  foetal  life,  into  a  solid 
material,  which,  at  the  same  time,  shoots  downward,  and  gives 
to  every  tooth  a  neck  or  fang." 

The  period  of  dentition  here  referred  to  is  the  time  when  the 
sac  begins  to  contract.  The  coronal  extremity  of  the  tooth  is 
then  brought  in  contact  with  the  sac,  and  when  the  formation 
of  the  root  of  the  former  proceeds  more  rapidly  than  the  con- 
traction of  the  latter,  the  root  comes  in  contact  with  the  bottom 
of  the  alveolus,  and  doubtless  much  of  the  irritation,  as  we  have 
before  intimated,  resulting  from  dentition,  is  attributable  to 
this  circumstance.  But  Dr.  G.  is  mistaken  in  supposing  that 
the  pulpy  rudiment  begins  to  be  converted  into  a  solid  material 
at  ^he  third  or  fourth  month  of  infancy,  when,  what  he  terms, 
the  first  or  active  stage  of  teething  commences.  Several  layers 
of  dentine  are  perfectly  formed  over  most  of  the  pulps  of  the 
temporary  teeth  at  birth,  though  the  enamel  is  not  quite  com- 
pleted at  so  early  a  period.  The  doctor  has  evidently  confounded 
the  commencement  of  the  elongation  of  the  pulp  with  that  of  its 
solidification. 

During  the  period  of  teething,  the  child  is  restless  and  fretful, 
but  its  paroxysms  of  suffering  are  periodical,  and  seldom  last 
more  than  two  or  three  hours  at  a  time ;  whereas,  were  the 
pressure  of  the  teeth  upon  the  gums  uniform  and  constant,  there 
would  be  no  intermissions.  The  repose  thus  afforded,  enables 
the  system  to  recover  in  some  degree  from  the  exhaustion  occa- 
sioned by  each  preceding  paroxysm.  If  it  were  not  for  this,  its 
excited  energies  would  soon  be  worn  out,  and  the  child  fall  a  vic- 
tim to  the  continued  intensity  of  its  sufferings. 

When  the  irritation  is  merely  local,  it  is  usually  of  short  du- 
ration, and  consists  in  a  slight  tenderness  and  tumefaction  of  the 
gums,  accompanied  by  increased  secretion  of  saliva.  But  when 
it  is  suflBciently  great  to  affect  the  functional  operations  of  other 
parts  of  the  system,  febrile  symptoms  of  a  general  and  more  or 
less  aggravated  character  supervene,  attended  with  drowsiness, 
diarrhoea,  and  not  unfrequently,  with  various  cutaneous  eruptions ; 
such  as  the  red  gum,  also  pustules,  at  first  filled  with  limpid  fluid, 


EFFECTS    OF   FIRST   DENTITION.  123 

hut  which,  afterwards,  hecome  purulent.  The  former  appear  on 
the  neck  and  face  :  the  latter  are  not  confined  to  any  particular 
part  of  the  body,  but  are  either  thinly  scattered  over  its  whole 
surface,  or  appear  in  small  patches.  There  is  also  another  kind 
of  eruption  which  breaks  out  about  the  mouth,  cheeks  and  fore- 
head, sometimes  extending  to  the  scalp ;  which,  in  a  short  time 
dries  up  and  becomes  covered  with  disagreeable  scabs.  These 
drop  oif,  after  a  while,  to  be  succeeded  by  others. 

These  eruptions  are  generally  regarded  as  indications  of  the 
substitution  of  a  milder  for  a  more  aggravated  form  of  disease, 
and  should  not,  therefore,  be  too  hastily  suppressed. 

To  these  symptoms,  we  may  add,  cough,  spasms  of  the  mus- 
cles of  the  face,  particularly  of  those  about  the  mouth ;  and,  when 
the  diarrhoea  is  so  copious  as  to  occasion  great  emaciation,  con- 
vulsions and  death,  sometimes,  supervene. 

Thus  far,  we  have  merely  glanced  at  a  few  of  the  effects  of 
first  dentition.  To  attempt  a  description  of  all,  would  involve 
the  enumeration  of  the  whole  catalogue  of  diseases  peculiar  to 
infancy ;  but  which,  as  they  more  properly  belong  to  another 
branch  of  medicine,  we  shall  neither  stop  to  describe  nor  point 
out,  minutely,  their  curative  indications. 

It  may  be  well,  however,  to  state,  that  the  local  treatment 
consists  in  making  a  free  incision  with  a  lancet  through  the  tume- 
fied gum,  down  to  the  advancing  tooth.  This,  in  very  many 
cases,  affords  immediate  relief  and  supersedes  the  necessity  of 
other  treatment.  It  is  objected  to  by  some,  on  the  ground,  that, 
though  it  may  afford  temporary  relief,  the  cicatrix,  formed  by  the 
healing  of  the  wound,  constitutes  a  greater  obstacle  to  the  exit 
of  the  tooth,  than  the  parts  ever  do  when  left  to  themselves. 
Now,  any  one  at  all  conversant  with  the  subject,  knows  that  in 
four  cases  out  of  five,  where  the  operation  is  necessary,  the  teeth 
are  so  far  advanced,  that  when  the  incised  gums  collapse,  their 
crowns  immediately  protrude :  and  even  when  the  wound  does 
unite,  the  soft  and  spongy  cicatrix  yields  more  readily  to  the 
action  of  the  absorbents  than  the  gums  do  in  their  natural  state. 

Another  objection  is  founded  upon  the  supposition  that  the 
enamel,  at  this  early  period,  is  in  a  soft  and  amorphous  state, 
and  that,  consequently,  the  teeth  may  be  injured  by  the  contact 
of  the  knife.     But  as  the  parts  of  the  enamel  exposed  to  the  in- 


124 


EFFECTS   OF   FIRST   DENTITION. 


strument  usually  attain  their  greatest  hardness  before  such  ope- 
ration is  required,  this  objection  is  Avithout  foundation.  In  short, 
■we  have  never  known  any  injury  to  result  from  it,  either  in  our 
own  practice,  or  in  that  of  others  :  nor  can  those  who  are  opposed 
to  it,  bring  facts  to  support  their  opposition. 

It  is  true,  there  is  sometimes  considerable  hemorrhage,  which, 
in  two  or  three  instances,  has  terminated  fatally,  but  it  rarely 
happens  that  this  is  very  considerable,  and  it  almost  always  sub- 
sides in  a  few  minutes. 

This  simple  operation  often  succeeds  after  all  other  attempts 
to  afford  relief  have  failed.  We  have  frequently  known  children, 
after  having  suffered  the  greatest  agony  for  days  and  weeks  and 
until  they  had  become  reduced  to  mere  skeletons,  obtain  imme- 
diate relief  without  any  other  treatment.  This  at  once  removes 
the  cause ;  whereas,  other  remedies  only  counteract  the  effects  of 
the  suffering,  and  can  only  be  considered  as  palliatives  that  may 
assist  nature  in  her  struggles  with  disease,  but  cannot  always 
prevent  her  from  sinking  in  the  contest. 


CHAPTER   NINTH. 
SHEDDING  OF  THE  TEMPORARY  TEETH. 

Some  very  singular  notions  were  entertained  among  the  an- 
cients concerning  the  temporary  teeth.  Many  thought  they 
never  had  roots,  inasmuch  as  they  were  observed  to  be  wanting 
when  they  dropped  out ;  others,  that  the  crowns  were  removed, 
while  the  roots  remained  and  afterwards  grew  and  became  the 
permanent  teeth. 

The  shedding  of  the  temporary  teeth,  a  most  wonderful  opera- 
tion of  the  economy,  is  effected  in  accordance  with  an  established 
law  ;  but  there  exists,  among  physiologists,  some  difference  of  opin- 
ion with  regard  to  the  precise  manner  in  which  it  is  effected.  Most 
writers  ascribe  their  destruction  to  the  action  of  the  absorbents. 
Mr.  Fox  supposes,  that  as  the  new  teeth  begin  to  rise  from  their 
sockets,  they  come  in  contact  with,  and  press  upon,  first,  the 
partition  of  bone  intervening  between  them  and  the  roots  of  the 
temporaries,  and  afterwards  upon  the  roots  themselves  ;  and  this 
pressure,  he  believes,  induces  their  absorption.  He  afterwards, 
however,  admits  that  pressure  is  not  necessary  to  their  absorp- 
tion, as  it  sometimes  takes  place  where  there  is  none. 

Mr.  Hunter  does  not  attempt  to  explain  the  manner  of  the 
destruction  of  the  roots  of  the  temporary  teeth  in  any  other  way 
than  by  stating,  that  they  decay  off  up  to  the  gum.  Fauchard 
and  Bourdet  attribute  their  removal  to  the  action  of  a  corrosive 
fluid,  supplied  for  the  special  purpose.  Bunon  thinks  they  are 
worn  away  by  the  rising  teeth.  Lecluse  is  of  the  opinion  that 
when  the  process  of  their  removal  begins,  their  vessels  cease  to 
supply  nourishing  juices,  and  that  they  are  broken  up  by  a  spe- 
cies of  maceration  ;  while  Jourdain  thinks  it  is  both  by  abrasion 
and  corrosion. 

Mr.  Bell,  as  do  indeed  almost  all  recent  writers,  adopts  the 
theory  of  Mr.  Fox,  that  the  destruction  of  the  roots  of  the  tem- 
porary teeth  is  the  result  of  absorption.     Laforgue,  observing  a 


126  SHEDDING    THE    TEMPORARY  TEETH. 

fungiform  or  carneous  substance  behind  the  root  of  the  temporary 
tooth — which,  in  fact,  had  been  noticed  by  Bourdet,  and  sup- 
posed by  him  to  exhale  a  fluid  possessed  of  solvent  qualities — gave 
it  the  name  of  absorbing  apparatus,  and  assigned  to  it  the  office 
of  removing  the  root  of  the  primary  tooth. 

Delabarre,  who  has  treated  this  subject  at  greater  length  and, 
apparently,  investigated  it  more  closely,  corroborates  the  views 
of  Laforgue,  and  gives  the  following  idescription  of  the  manner 
of  the  formation  and  function  of  the  carneous  substance  spoken 
of  by  this  author.  "  While  the  crown  of  the  tooth  of  replace- 
ment," says  Delabarre,  "is  yet  in  formation,  the  external  mem- 
brane of  the  matrix  is  simply  crossed  by  a  few  blood-vessels  ;  but 
as  soon  as  it  is  completed,  the  capillaries  are  then  developed  in 
a  very  peculiar  manner,  and  form  a  tissue  as  fine  as  cobweb  ; 
from  this  tissue  the  internal  membrane,  instead  of  continuing 
very  delicate,  and  of  a  pale  red  color,  increases  in  thickness  and 
assumes  a  redder  hue.  As  was  before  said,  it  is  at  the  instant 
in  which  the  contraction  of  the  coats  of  the  matrix  commences, 
(investments  which  extend  from  the  gum  to  the  neck  of  the  tooth), 
that  the  congeries  of  vessels  entering  into  their  tisssue,  assist  in 
forming  a  body  of  a  carneous  appearance,  Avhose  absorbents  ex- 
tend their  influence  over  all  the  surrounding  parts ;  it  is,  there- 
fore, the  dental  matrix  itself,  which,  after  being  dilated  to  serve 
as  a  protecting  envelop  to  the  tooth,  is  contracted  to  form — not 
only  this  bud-like  body  which  we  find  innnediately  below  the 
milk  tooth  at  the  instant  in  which  it  naturally  falls  out,  and 
whose  volume  is  necessarily  augmented  as  odontoseisis  gradually 
goes  on ;  but  also  a  carneous  mass  by  which  the  whole  is  sur- 
rounded, and  whose  thickness  is  the  more  remarkable  as  the 
organ  that  it  envelops  is  nearer  its  orifice." 

After  giving  this  description,  he  asks,  "  Is  there  a  dissolving 
fluid  that  acts  chemically  on  the  surrounding  parts ;  or  do  the 
absorbents,  without  any  intermediate  agency,  destroy  everything 
that  would  obstruct  the  advance  of  the  tooth?"  In  reply  to 
this,  he  says,  "Not  possessing  positive  proof  to  guide  me  in  the 
decision  of  these  questions,  and  finding  the  evidence  of  others  of 
little  importance,  I  shall  not  attempt  to  answer  them." 

In  pursuing  this  subject  further,  he  states  that  the  vessels  of 
the  temporary  tooth  often  remain  entire  in  the  midst  of  this  car- 


SHEDDING   THE   TEMPORARY  TEETH.  127 

neous  (fleshy)  substance,  and  continue  to  convey  their  fluids  to 
the  central  parts,  whilst  the  calcareous  ingredients  and  the  gela- 
tine have  been  removed ;  but  that,  at  other  times,  they  too,  are 
destroyed.  The  conclusion  to  which  he  arrives,  after  a  careful 
examination  of  the  whole  subject,  is  ;  that  whether  the  earthy  and 
animal  parts  of  the  roots  are  removed  by  the  absorbents  of  the 
carneous  tubercle  in  question  without  previous  change,  or  whether 
they  are  decomposed  by  the  chemical  action  of  a  fluid  exhaled 
from  it,  they  are  ultimately  carried  back  into  the  general  circu- 
lating system. 

In  proof  of  the  agency  of  the  carneous  tubercle  in  the  destruc- 
tion of  the  roots  of  the  temporary  teeth,  he  mentions  one  fact 
that  goes  very  far  to  establish  the  truth  of  the  opinion  that  it 
does  so  ;  and  which,  if  his  views  be  correct,  will  account  for  those 
cases  occasionally  to  be  met  with,  in  which  one  or  more  of  the 
permanent  teeth  fail  to  appear.  It  is  this  :  if  the  carneous  sub- 
stance fails  to  be  developed,  or  is  destroyed,  the  successional 
tooth  remains  in  its  socket,  and  never  makes  its  appearance. 
Cases  of  this  kind  have  fallen  under  the  notice  of  almost  every 
dentist. 

In  as  few  words  as  possible  we  have  given  the  views  of  this 
ingenious  writer  on  the  subject  under  consideration  ;  and  although 
they  do  not  seem  to  have  attracted  much  attention  from  English 
writers,  and  are  rejected  by  Mr.  Bell  on  the  ground,  that  the 
destruction  of  the  root  of  the  temporary  tooth  frequently  com- 
mences on  a  part  "the  most  remote  from  the  sac  of  the  perman- 
ent tooth,"  we  are  disposed  to  believe  them,  for  the  most  part, 
correct,  the  more  especially  since  we  entirely  disagree  with  Mr. 
Bell.  As  to  the  existence  of  the  fleshy  tubercles,  there  can  be 
no  question,  and  that  it  is  through  the  agency  of  these  that  the 
roots  of  the  temporary  teeth  are  destroyed,  seems  more  than 
probable.  But,  whether  it  is  through  the  agency  of  their  absor- 
bent vessels  or  a  chemical  fluid  exhaled  for  the  purpose,  may  not, 
as  Delabarre  says,  be  so  easy  to  determine.  We  are  inclined  to 
believe,  however,  that  the  latter  agent  is  the  one  principally  con- 
cerned in  efi"ecting  the  destruction  of  the  fangs,  and  for  the  rea- 
son that  if  litmus  paper  be  applied  to  the  fleshy  tubercle,  imme- 
diately after  the  crown  of  a  temporary  tooth  has  fallen  out  or 
been  removed,  it  turns   red,  thus  showing  the  presence  of  an 


128  SHEDDING    THE    TEMPORARY  TEETH. 

acid.  That  the  absorbents  have  something  to  do  in  this  process, 
is,  we  think,  very  probable  ;  but  we  believe  the  operation  of  these 
delicate  vessels  is  here  always  preceded  by  the  action  of  a  chemi- 
cal agent. 

The  change  that  takes  place  in  the  external  membrane  of  the 
sac,  as  noticed  by  Delabarre,  is  observable,  first,  on  the  peduncle 
or  chord  leading  from  it  to  the  gum  behind  the  temporary  tooth. 
It  here  becomes  thickened  about  the  time  that  the  root  of  the 
new  tooth  begins  to  form,  and  assumes  a  fleshy  appearance,  and 
it  is  here  that  the  destruction  of  the  surrounding  bone  com- 
mences, enlarging  the  alveolo-dental  canal,  and  gradually  remov- 
ing the  intervening  bony  partition,  and  finally,  the  root  of  the 
temporary  tooth.  The  agency  of  this  thickened  and  fleshy  con- 
dition of  the  external  membrane  of  the  capsule  in  the  removal  of 
the  roots  of  the  temporary  teeth  is  rendered  more  conclusive  by 
the  fact,  that,  in  those  cases  in  which  the  roots  of  the  permanent 
teeth  have  become  partially  destroyed,  the  alveolo-dental  perios- 
teum presents  a  similar  appearance.  In  the  formation,  too,  of 
alveolar  abscess,  the  tubercle  at  the  extremity  of  the  root  pre- 
sents a  like  aspect.  There  also  seems  to  be,  in  this  interesting 
operation  of  the  economy,  an  association  of  functions  mutually 
dependent  upon  each  other ;  so  that,  if  one  be  suspended,  the 
others  fail  to  be  performed.  Thus,  if  from  any  cause,  the  sac 
fails  to  contract,  the  fleshy  tubercle  is  not  developed,  nor  does 
the  formation  of  the  root  take  place ;  consequently,  the  crown 
of  the  tooth  remains  in  its  alveolus.  Harmonious  consent  of  as- 
sociated actions  are  nowhere  more  beautifully  exemplified,  than 
in  these  three  operations. 

It  often  happens,  that  the  root  of  a  temporary  tooth  fails  to 
be  destroyed,  and  that  the  crown  of  the  replacing  organ  comes 
through  the  gum  in  a  wrong  place.  Whenever  this  occurs,  the 
cameous  body  is  developed  only  beneath  the  parts  through  the 
opening  of  which  the  new  tooth  has  appeared,  and  is  not  brought 
in  contact  with  the  bony  partition,  between  it  and  the  root  of 
the  temporary  tooth. 

The  manner  of  the  destruction  of  the  roots  of  the  temporary 
teeth  has  been  a  subject  of  careful  inquiry  with  the  author  for 
several  years ;  and  the  more  he  has  examined  it,  the  more  fully 
has  he  become  convinced,  that  it  is  the  result  of  the  action  of 


SHEDDING    THE    TEMPORARY  TEETH.  129 

this  fleshy  tubercle.  While  its  formation  would  seem  to  be  the 
result  of  the  contraction  of  the  dental  sac  and  its  appendage,  for 
the  purpose  of  effecting  the  eruption  of  the  tooth,  it  is  especially 
charged  with  the  removal  of  everything  that  would  obstruct  its 
passage. 

In  conclusion,  it  is  only  necessary  to  observe  that  the  tempo- 
rary teeth  are  shed  in  the  same  order  in  which  they  appear. 
After  one  pair  has  been  shed,  a  sufficient  time  usually  elapses 
before  the  shedding  of  another,  for  those  of  the  same  class  of 
the  permanent  set  to  come  forward  and  take  their  place.  Thus, 
the  jaws  are  never  deprived,  unless  from  some  other  cause  than 
the  destruction  of  the  roots  of  the  temporary  set,  of  more  than 
two  teeth  in  each  jaw  at  any  one  time. 


CHAPTER    TENTH. 
SECOND  DENTITION. 

There  are  no  operations  of  the  animal  economy  more  singular 
or  interestincr  than  those  exhibited  in  the  gradual  destruction  of 
the  roots  of  the  temporary,  and  in  the  growth  and  eruption  of 
the  permanent  teeth.  The  time  of  life  when  they  occur,  consti- 
tutes an  important  epoch  in  the  history  of  every  individual. 

During  childhood,  the  alveolar  arches  form  only  about  half  a 

circle,  but  by  the  gradual  elongation  of  the  jaws  they  ultimately, 

at  adult  age,  form  nearly  the  half  of  an   ellipsis ;  so  that  the 

number  of  teeth  required  to  fill  them  at  the  one  period,  is  but 

little  more  than  half  the  number  required  at  the  other. 

Moreover,  the  food  of  children  is  principally  vegetable,  re- 
quiring but  little  mastication  to  prepare  it  for  the  stomach ; 
whereas,  that  of  adults  consists  of  an  almost  equal  additional 
portion  of  animal  matter,  which,  owing  to  the  greater  cohesion 
of  its  particles,  require  a  more  numerous  and  substantial  set  of 
instruments  for  its  trituration. 

So  admirable  is  the  economy  of  second  dentition,  that  even 
before  the  shedding  of  the  temporary  teeth  commences,  and  as 
soon  as  the  jaws  are  sufficiently  enlarged,  four  of  the  second 
set,  one  on  each  side,  in  each  maxilla,  make  their  appearance. 
Consequently,  the  number  of  teeth,  after  the  completion  of  the 
first  set,  is  never  diminished,  unless  by  accident  or  disease. 

The  rudiments  of  the  permanent  incisors  and  cuspids  have 
attained  their  full  size  at  birth,  and  each  is  situated  immediately 
behind  its  corresponding  temporary  tooth. 

The  permanent  teeth,  with  the  exception  of  the  bicuspids,  are 
considerably  larger  than  the  temporary,  and  during  the  time  of 
their  formation  are  situated  in  the  segment  of  a  much  smaller 
parabola.  But  before  the  shedding  of  the  first  set  begins,  the 
successional  teeth,  by  an  increase  in  the  depth  of  the  jaws,  and 
the  development  of  the  alveolar  processes,  are  brought  forward; 


SECOND    DENTITION.  131 

and,  at  about  the  fifth  year,  they  are  situated  immediately  be- 
neath the  deciduous  in  the  lower,  and  nearly  above  them  in  the 
upper  maxilla,  occupying  places  in  the  alveolar  border,  corres- 
ponding in  depth  to  the  length  of  their  respective  roots. 

By  this  arrangement  the  permanent  teeth  occupy  the  smallest 
possible  space  in  the  jaws.  The  central  incisors  and  cuspids 
nearly  fill  the  anterior  part  of  the  arch,  while  the  lateral  are 
thrown  behind  and  partly  between  them. 

The  following  concise  description  of  the  relative  position  of 
the  teeth,  at  the  fifth  year  after  birth,  is  given  by  Mr.  Bell.  "  In 
the  upper  jaw,  the  central  incisors  are  situated  immediately  be- 
neath the  nose,  the  lateral  incisors  are  thrown  back  behind  the 
points  of  the  cuspids,  and  the  base  of  the  latter  is  scarcely  a 
quarter  of  an  inch  below  the  orbit.  In  the  lower  jaw,  the  cus- 
pids are  placed  at  the  very  base  of  the  bone,  with  only  a  thin 
layer  beneath  them,  but  the  crowding  is  much  less  considerable 
than  in  the  upper  jaw,  from  the  smaller  comparative  size  of  the 
incisors. 

"The  permanent  central  incisor  of  the  lower  jaw  is  placed 
immediately  beneath  the  temporary,  with  its  point  directed  a 
little  backwards,  behind  the  partially  absorbed  root  of  the  latter. 
The  lateral  incisor,  not  yet  so  far  advanced,  is  placed  deeper  in 
the  jaw,  and  instead  of  being  immediately  beneath  the  tempo- 
rary, is  situated  with  its  point  between  the  roots  of  this  and 
the  cuspid.  The  permanent  cuspid  is  still  very  deeply  im- 
bedded in  the  bone,  with  its  point  resting  between  the  roots  of 
the  temporary  cuspid  and  the  first  temporary  molar.  The 
two  spreading  roots  of  the  latter  encompass,  as  it  were,  within 
their  span,  the  first  bicuspid;  and  those  of  the  second  temporary 
molar,  in  like  manner,  grasp  the  second  bicuspid.  Nearly  a 
similar  arrangement  is  found  to  exist  in  the  upper  jaw,  except 
that  the  teeth  are  altogether  more  crowded." 

In  Fig.  52  is  exhibited  a  front  and  side  view  of  the  superior 
and  inferior  maxillary  bones,  with  the  temporary  teeth  in  situ, 
the  outer  wall  of  the  alveolar  border  being  removed,  shows  the 
situation  of  the  crowns  of  the  permanent  incisors,  cuspids,  bi- 
cuspids and  first  molars. 

The  irritation  consequent  upon  the  eruption  of  the  permanent 
teeth,  is  usually  very  slight,  andVith  the  exception  of  the  dentes 


132 


SECOND    DENTITION. 


sapienti*,  seldom  occasions  much  inconvenience.     This  is  owing 
Fig.  52.  to  the  fact,  that  when  second  denti- 

tion commences,  the  system  has 
acquired  so  much  vigor  and 
strength,  as  not  to  be  easily  aflfect- 
ed  by  slight  morbid  impressions; 
and  the  gums  offer,  comparatively, 
little  resistance  to  the  eruption  of 
the  teeth  of  replacement,  for  when 
the  temporaries  drop  out,  the  others 
are  generally  so  far  a'(ivanced  as 
Fig  52.  A  view  of  the  superior  and  in- to     appear     almost     immediately. 

ferior  maxillary  bones  of  a  child  about  four  i  •      • 

years  old.  with   their  exterior  and    outer  Evcn  whcU  tlllS  IS  nOt  the   CaSC,  the 

walls  removed,  so  as  to  show  the  crowns  of 

the  permanent  teeth  behind  the  roots  of  the   cicatrix  that  formS  OVer  the  DCrma- 

temporary.    The  superior  maxillary  bones  ^ 

are  separated  at  the  median  line,  and  about  ngut  tOOth  is  of  SO  SDOnffV  a  teXtUrC 

a  quarter  of  an  inch  apart.     Behind  the  se-  "       OJ 

cond  temporary,  are  seen  the  crowns  of  the  f}.r,f  ]f  rpnflilv  viplds    to  thp    af>tioT1 

first  permanent  teeth  imbedded  in  the  alve-  ^^^^  ^^  TCaUliy  ^  leiUS    lO  me    dtllUIl 

"'""•^s^-  of  the  absorbents.     The    process, 

too,  is  more  gradual,  from  six  to  eight  years  being  required 
for  its  completion,  while  the  eruption  of  the  teeth  of  first  denti- 
tion is  accomplished  in  less  than  half  that  time. 

Second  dentition  usually  commences  about  six  or  seven  years 
after  birth,  and  is  generally  completed,  as  far  back  as  the 
second  molars,  by  the  twelfth  or  fourteenth  year.  The  dentes 
sapientise  seldom  appear  before  the  eighteenth  or  twentieth  year. 
The  periods  for  the  eruption  of  the  adult  teeth  are,  however,  so 
variable,  that  it  is  impossible  to  state  them  with  perfect  accuracy. 
Sometimes  the  first  permanent  molars  appear  at  four  years,  and 
the  central  incisors  at  five ;  at  other  times,  these  teeth  do  not 
appear  before  the  ninth  or  tenth  year. 

But  as  it  is  of  some  importance  that  the  periods  of  the  erup- 
tion of  the  several  classes  of  the  permanent  teeth  should  be 
known,  we  will  state  them  with  as  much  accuracy  as  possible. 

First  molars,         from 

Central  incisors,     " 

Lateral  incisors,     " 

First  bicuspids,       " 

Second  bicuspids,   " 

Cuspids,  " 

Second  molars,       " 

Third  molars,  (dentes  sapientiae,) 


5  to    6  years 

6  to    8 

7  to    9 

9  to  10 

10  to  111 

11  to  12     ' 

12  to  14     ' 

17  to  21     < 

ACCRETION    OF    THE    JAWS.  133 

But,  as  before  stated,  the  periods  for  the  eruption  of  the  per- 
manent teeth,  like  those  of  the  temporary,  are  exceedingly  va- 
riable. The  cuspids  often  appear  before  the  second  bicuspids, 
and  in  some  cases,  the  dentes  sapientige  not  until  the  thirtieth  or 
even  fortieth  yeai-,  and  sometimes  they  never  show  themselves. 

The  author  is  acquainted  with  a  gentleman  who  did  not  shed 
his  left  superior  cuspid  until  he  was  twenty.  A  few  months 
after,  the  permanent  cuspid  made  its  appearance.  In  fact, 
he  has  known  the  temporary  cuspids  in  several  instances  to  re- 
main until  the  fortieth  year,  but  when  shed  at  this  late  age  they 
are  rarely  replaced.  In  the  General  Archives  of  Medicine  for 
June,  1840,  the  case  of  a  woman  is  recorded,  who,  at  the  age  of 
forty-three,  acquired  four  permanent  incisors,  behind  the  tempo- 
rary, which,  up  to  this  period,  had  not  been  shed.  Four  molars 
made  their  appearance  a  year  later ;  and  M.  Desirabode  says  he 
has  met  with  similar  cases. 

Maury  fixes  the  period  for  the  eruption  of  the  four  first  molars 
at  from  six  to  eight  years,  and  Desirabode  at  from  six  to  seven, 
but  we  have  rarely  known  them  to  delay  their  appearance  be- 
yond the  sixth  year.  Both  of  these  authors,  too,  place  the  cus- 
pids, in  the  order  of  the  eruption  of  the  teeth,  before  the 
second  bicuspids. 

ACCRETION  OF  THE  JAWS. 

As  the  rudiments  of  the  temporary  teeth  increase  in  size,  a 
corresponding  increase  in  the  maxillary  bones  takes  place,  but 
during  the  earlier  stages  of  the  formation  of  the  permanent 
teeth  their  growth  is  not  so  manifest.  At  about  two  and  a  half 
years  after  birth,  they  begin  to  elongate,  and  generally,  at  the 
fifth  year,  have  acquired  sufficient  length  to  admit  behind  the 
second  temporary,  the  first  permanent  molars.  After  the  com- 
pletion of  first  dentition,  the  part  of  the  alveolar  border  occu- 
pied by  this  set  of  teeth,  augment  in  dimensions  but  very  little. 
The  increase,  after  this  time,  is  chiefly  confined  to  the  back 
part  of  the  jaw,  between  the  second  temporary  molars  and  the 
coronoid  processes  in  the  lower,  and  the  maxillary  tuberosities 
in  the  upper.  The  anterior  part  of  the  jaws  do,  however,  aug- 
ment a  little,  although  so  inconsiderable  is  the  increase  here, 


134  ACCRETION    OF   THE    JAWS. 

that  some,  and  among  whom  are  Hunter  and  Fox,  have  been  in- 
duced to  deny  the  fact.  By  the  admeasurement  of  various 
jaws,  at  different  ages,  the  writers  just  named  have  endeavored 
to  prove,  that  the  superiority  in  size  of  the  permanent  over  the 
temporary  incisors  is  not  greater  than  the  difference  existing 
between  the  temporary  molars  and  the  bicuspids  to  the  advan- 
tage of  the  former,  and  that,  consequently,  no  increase  in  this 
part  of  the  jaw  is  necessary.  But  a  measurement  of  the  same 
jaw,  made  after  the  first  permanent  molars  have  come  through 
the  gums,  then  again  after  the  eruption  of  all  the  teeth  of  re- 
placement, will  show  that  their  measurements  are  not  to  be 
relied  on. 

M.  Delabarre,  in  attempting  to  prove  the  incorrectness  of  these 
gentlemen's  calculations,  by  a  similar  course  of  experiments, 
appears  to  have  fallen  into  an  opposite  error ;  whence,  it  would 
seem,  as  is  justly  remarked  by  Mr.  Bell,  "  that  no  comparison, 
instituted  between  the  jaws  of  different  individuals,  can  be  relied 
on  as  conclusive."  The  only  way  by  which  we  can  arrive  at 
the  truth  of  the  matter  is  by  examining  the  same  jaw  at  different 
ages,  and  comparing  the  several  results.  "  This,"  says  Mr.  B., 
"  I  have  repeatedly  done,  and  have  no  hesitation  in  saying,  that 
the  ten  anterior  permanent  teeth  occupy  a  somewhat  larger  arch 
than  the  temporary  ones  which  preceded  them  had  done." 

The  transverse  and  perpendicular  dimensions  of  the  anterior 
part  of  the  jaws  continue  to  augment  until  the  completion  of 
second  dentition. 

In  alluding  to  the  influence  which  the  pressure  of  the  teeth 
has  in  determining  an  increase  of  the  anterior  part  of  the  jaws, 
Delabarre  contends,  that  while  any  immediate  pressure  of  these 
organs  is  impossible  except  at  the  time  when  they  are  forcing 
their  way  tlnougli  tlie  enlarged  alveola-dental  canals,  their  con- 
tact, at  this  period,  gives  rise  to  a  mechanical  increase;  and  he 
believes  that,  previously  to  this  period,  the  enlargement  is  carried 
on  by  the  liquor  contained  in  the  dental  sacs.  He  argues,  there- 
fore, that  the  jaws,  besides  the  mode  of  accretion  resulting  from 
nutrition,  "  have  another,  peculiar  to  themselves,"  coinciding 
with  the  development  of  the  dental  sacs,  and  the  quantity  of  fluid 
which  they  contain  ;  as  also  with  the  manner  of  the  arrangement 
of  the  crowns  of  the  permanent  teeth  between  such  as  may  be 
in  the  circle,  whether  belonging  to  first  or  second  dentition. 


ACCRETION    OF    THE    JAWS.  135 

That  the  dimensions  of  the  alveolar  arch  may  be  increased  by 
pressure  upon  the  teeth  from  behind  forward,  no  one  will  deny; 
but  to  suppose  the  accretion  of  the  jaws  may  be  determined  by 
the  pressure  of  these  organs  against  each  other,  or  by  the  fluid 
contained  in  the  dental  sacs,  would  be  to  suppose  that  the  law 
that  determines  growth  in  other  bones,  is  inoperative  here.  In 
fact,  to  do  this,  would  be  attributing  it  rather  to  accident  than 
to  a  natural  operation  of  the  economy.* 

The  elongation  of  the  jaws  produce  a  corresponding  change  in 
the  form  of  the  face.  Thus,  the  face  of  a  child  is  round,  that  of 
an  adult  is  long  and  prominent. 

The  permanent  incisors  usually  fill  the  space  formerly  occu- 
pied by  the  temporaries  of  the  same  class,  and  about  one-half  of 
that  previously  filled  by  the  primitive  cuspids.  The  other  half 
of  this  space,  together  with  a  moiety  of  that  before  taken  up  by 
the  first  temporary  molars,  is  occupied  by  the  permanent  cuspids. 

The  bicuspids  occupy  spaces  larger  by  one-fifth  or  sixth  than 
those  occupied  by  the  remaining  moiety  of  the  first,  and  the 
whole  of  the  second  temporary  molar. 

Hence,  it  will  be  perceived  that  the  ten  anterior  permanent 
teeth  occupy  a  somewhat  larger  space  than  that  taken  up  by  the 
temporary  ones  which  preceded  them,  and  that,  were  there  no 
increase  in  the  size  of  this  portion  of  the  arch,  the  regularity  of 
their  arrangement  would  be  more  or  less  disturbed.  To  prevent 
this  a  slight  increase  is  necessary,  but  the  dimensions  of  that 
portion  of  the  alveolar  border  occupied  by  the  temporary  teeth 
is  not  materially  increased  until  these  teeth  are  shed,  and 
then,  as  those  of  replacement  come  forward  to  take  their  place, 
they  arrange  themselves  in  a  somewhat  larger  arch.  It  is  in 
this  manner  that   the  size  of  the  alveolar  border  is  augmented. 

*  The  formation  of  the  alveolar  processes,  and  that  of  the  teeth,  take  place  accord- 
ing to  different  laws.  The  jaws  grow  and  enlarge  in  conformity  with  the  general 
laws  which  pre.-ide  over  the  increase  of  the  osseous  system.  The  alveolar  arches,  at 
birth,  are  little  more  than  one  inch  in  length  ;  at  nine  years  of  age,  they  arc  nearly 
two  inches,  and  at  the  period  of  perfect  growth,  at  least  two  inches  and  a  half  long. 
The  de,ith  of  the  lower  jaw  in  the  fetus  at  the  full  time  is  one-seventh,  and  in  the  adult 
one-fifih  of  the  whole  weight  of  the  head.  The  teeth,  on  the  contrary,  uuiformly 
appear  with  the  breadth  and  thickness  only,  not  the  length,  to  which  they  will  ever 
attain.  In  order  that  the  development  of  these  organs  may  take  place  in  a  regular 
mauner,  it  is,  therefore,  necessary  that  a  certain  harmony  be  established  between  their 
sizes  at  different  periods,  and  the  alveolar  ridges  of  the  jaws. — Bottrgcry'ii  Anatomy. 


136  ACCRETION    OF   THE   JAWS. 

In  fact,  a  new  alveolar  ridge  is  formed,  and  this  last  is  slightly 
larger  than  the  first. 

But  there  is  not  always  an  increase  in  the  anterior  part  of  the 
jaws ;  on  the  contrary,  the  premature  loss  of  one  or  more  of  the 
temporary  teeth  often  occasions  a  contraction  that  frequently 
causes  irregularity  of  the  permanent  set,  and  sometimes  forces 
the  first  and  second  molars  so  far  back  that  the  dentes  sapientise 
are  thrown  against  the  coronoid  processes ;  and  thus,  in  many 
instances,  producing  such  severe  inflammation  in  the  muscles  of 
this  portion  of  the  jaw,  that  the  extraction  of  these  latter  teeth 
is  rendered  absolutely  necessary. 

About  the  third  year,  the  jaws  are  more  rapidly  elongated,  in 
order  that  the  first  permanent  molars,  which  are  at  this  time 
slowly  advancing,  may  find  room  behind  the  second  temporary 
molars.  This  elongation  continues  until  the  dental  arches  have 
become  sufficiently  enlarged  for  the  reception  of  the  whole  of 
the  permanent  teeth. 

It  sometimes  happens  that  the  jaws  in  their  accretion  are 
badly  developed,  and  have  a  faulty  configuration.  This  may 
occur  with  one  or  both  jaws.  The  alveolar  arch  is  sometimes 
too  narrow,  having  a  compressed  appearance,  and  projecting  so 
far  forward  as  to  prevent  the  upper  lip  from  covering  the  front 
teeth,  thus  imparting  to  the  individual  an  exceedingly  disagree- 
able appearance.  In  cases  of  this  sort,  the  roof  of  the  mouth, 
instead  of  having  an  oval  arch,  presents  an  irregular  triangle. 
At  other  times  the  alveolar  arch  is  too  wide,  so  that  the  teeth 
are  separated  from  each  other,  giving  to  the  roof  of  the  mouth 
a  flattened  aspect. 

Similar  defects  are  met  with  in  the  configuration  of  the  lower 
jaw\  Its  sides  may  be  too  close  together,  causing  the  front 
teeth  to  project,  and  to  cross  and  strike  on  the  outside  of  the 
upper  incisors,  or  it  may  describe  too  large  a  circle. 

These  defects  are  regarded  as  hereditary,  and  are  more  pecu- 
liar to  some  nations  than  others.  The  tendency  to  them  is 
observable  in  early  childhood,  and  even  in  infancy.  Many  sup- 
pose they  are  determined  by  a  rickety  diathesis;  but  this  opinion 
has  been  proven  to  be  incorrect  by  the  fact,  that  those  aSected 
with  this  disease  generally  have  good  palates  and  well  developed 
jaws.     So  far,  indeed,  from  its  having  any  agency  in  their  pro- 


ACCRETION    OF   THE    JAWS.  137 

duction,  rickets  is  thought  by  some  to  be  produced  by  dentition. 
The  reason  assigned  for  this  belief,  is  its  frequent  occurrence  at 
the  period  of  life  when  this  process  is  going  on ;  but  this  opinion 
is  doubtless  as  incorrect  as  is  the  other  and  opposite  one.  These 
peculiarities  in  the  formation  of  the  jaws  no  doubt  often  result 
as  a  consequence  of  the  intermarriage  of  the  people  of  one 
nation  with  those  of  another,  or  of  near  blood  relations  with  one 
another.  The  upper  jaw  will  resemble  in  shape  and  size  that  of 
the  father,  and  the  lower  that  of  the  mother,  or  vice  versa ;  or 
deformity  may  be  present  in  both  jaws. 

There  is  a  species  of  deformity  in  the  upper  jaw,  the  cause  of 
which  is  equally  difficult  of  explanation,  characterized  by  one  or 
more  divisions  of  the  upper  lip,  alveolar  ridge  and  palatine  arch, 
and  necessarily  accompanied  by  irregularity  in  the  arrangement 
of  the  teeth.  This  deformity,  depending  on  the  arrest  of  growth 
in  the  originally  separated,  embryonic,  incisive  tubercles  (inter- 
maxillary bones),  super-maxillary  and  palate  bones,  is  always 
congenital,  and  often  exceedingly  difficult  to  remedy. 

Any  infringement  of  the  laws  of  growth,  or  disturbance  of 
the  functional  operations  of  any  of  the  organs  of  the  face  or 
head,  may,  we  have  no  doubt,  determine  an  improper  develop- 
ment of  the  jaws  and  a  bad  arrangement  of  the  teeth ;  on  the 
other  hand,  a  perfect,  correct  and  healthful  performance  of  the 
several  functions  of  all  the  parts  concerned  in  the  formation  and 
growth  of  this  portion  of  the  organism,  will  secure  a  natural 
development  and  configuration  of  the  maxillary  bones. 


10 


CHAPTER   ELEVENTH. 
METHOD  OF  DIRECTING  SECOND  DENTITION. 

There  is  nothing  more  destructive  to  the  beauty,  health  and 
durability  of  the  teeth,  and  no  disturbance  more  easily  prevented, 
than  irregularity  of  their  arrangement.  Also,  in  proportion  to 
the  deviation  of  these  organs  from  their  proper  position  in  the 
alveolar  arch,  are  the  features  of  the  face  and  the  expression  of 
the  countenance  injured.  It  also  increases  the  susceptibility  of 
the  gums  and  alveolo-dental  membranes  to  morbid  impressions. 

It  is  important,  therefore,  that  the  mouth  during  second  den- 
tition, should  be  properly  cared  for  ;  and  so  thoroughly  convinced 
is  the  author  of  this,  that  he  does  not  hesitate  to  say,  that  if 
timely  precautions  were  used,  there  would  not  be  one  decayed 
tooth  where  there  are  now  a  dozen. 

Much  harm,  it  is  true,  may  be  done  by  improper  meddling 
with  the  teeth  during  this  period,  but  this  so  far  from  inducing 
a  total  neglect,  should  only  make  those  having  the  care  of  chil- 
dren more  solicitous  in  securing  the  services  of  scientific,  accom- 
plished practitioners. 

For  the  judicious  management  of  second  dentition,  much  judg- 
ment and  a  correct  knowledge  of  the  normal  periods  of  the 
eruption  of  the  several  classes  of  teeth,  are  required.  All  un- 
necessary interference  with  these  organs,  at  this  early  period  of 
life,  should  certainly  be  avoided,  as  it  will  only  tend  to  mar  the 
perfection  at  which  nature  ever  aims.  The  legitimate  duty  of 
the  physician  being,  as  Mr.  Bell  correctly  observes,  "  the  regu- 
lation of  the  natural  functions  when  deranged,"  he  should  never 
anticipate  the  removal  by  nature,  of  the  temporary  teeth,  unless 
their  extraction  is  called  for  by  some  pressing  emergency,  such 
as,  a  deviation  of  the  permanent  ones  from  their  proper  place, 
alveolar  abscess,  or  exfoliation  of  the  alveolar  processes. 

Among  the  few  who  have  treated  this  subject  in  a  full  and 
philosophical  manner,  we  will  mention  Delabarre,  whose  work 


METHOD    OF    DIRECTING    SECOND    DENTITION.  139 

contains  more  explicit  directions  in  regard  to  it  tlian  any  which 
has  as  yet  appeared.  Owing  to  the  superficial  manner  in 
which  second  dentition  is  frequently  studied,  this  author  was  led 
to  remark,  "  that  the  laws  which  govern  the  expansion,  growth 
and  arrangement  of  the  teeth,  are  properly  the  patrimony  of  the 
physician,  who  should  understand  them,  in  order  to  direct  the 
dentist,  whenever  (wdiich  unfortunately  is  very  frequently  the 
case)  he  is  not  furnished  with  sufficient  information  on  all  the 
duties  of  his  profession."  That  this  was  necessary  at  the  time 
Delabarre  wrote,  cannot  be  doubted;  but  at  present  we  have 
many  men  in  the  dental  profession  better  qualified  to  judge  of 
what  is  required  in  cases  of  this  sort,  than  any  general  practitioner 
whose  attention  has  never  been  specially  directed  to  this  peculiar 
department  of  practice. 

The  mouth  should  be  frequently  examined  from  the  time  the 
shedding  of  the  deciduous  teeth  commences  until  the  completion 
of  second  dentition  ;  and  when  the  growth  of  the  permanent  teeth 
so  far  outstrips  the  destruction  of  the  roots  of  the  temporary  that 
the  former  are  caused  to  take  an  improper  direction,  such  of  the 
latter  as  have  occasioned  the  obstruction,  should  be  immediately 
removed.  In  the  dentition  of  the  upper  front  teeth,  this  should 
never  be  neglected ;  for,  when  they  come  out  behind  the  tempo- 
raries, as  they  most  frequently  do,  and  are  permitted  to  advance 
so  far  as  to  fall  on  the  inside  of  the  lower  incisors,  a  permanent 
obstacle  is  offered  to  their  subsequent  proper  adjustment. 

When  a  wrong  direction  has  been  given  to  the  growth  of  the 
lower  front  teeth,  they  are  rarely  prevented  from  acquiring  their 
proper  arrangement  by  an  obstruction  of  this  sort.  They  should 
not,  however,  on  this  account,  be  permitted  to  occupy  an  erroneous 
position  too  long ;  for  the  evil  will  be  found  easier  of  correction 
while  recent,  than  after  it  has  continued  for  a  considerable 
length  of  time.     The  irregularity  should  be  immediately  removed. 

The  permanent  central  incisors  of  the  upper  jaw  being  larger 
than  the  temporaries  of  the  same  class,  it  might,  therefore,  be 
supposed,  that  the  aperture  formed  by  the  removal  of  the  one, 
would  not  be  sufficient  for  the  admission  of  the  other,  without  an 
increase  in  the  size  of  this  part  of  the  maxillary  arch.  -It  should 
be  recollected,  however,  that  by  the  time  these  teeth  usually 
emerge  from  the  gums,  the  crowns  of  the  temporary  lateral  in- 


140  METHOD    OF    DIRECTING    SECOND    DENTITION. 

cisors  are  so  much  loosened  bv  the  partial  destruction  of  their 
roots,  as  to  yield  sufficiently  to  the  pressure  of  the  former,  to 
permit  them  to  take  their  proper  position  within  the  dental  cir- 
cle. When  this  does  not  happen,  the  temporary  laterals  should 
be  extracted.  j 

Under  similar  circumstances,  the  same  course  should  be  pur- 
sued with  the  permanent  lateral  incisors  and  the  temporary  cus- 
pids, and  also  with  the  permanent  cuspids  and  the  first  bicuspids. 

The  bicuspids  being  situated  between  the  fangs  of  the  tempo- 
rary molars,  are  seldom  caused  to  take  an  improper  direction  in 
their  growth.  Nor  are  they  often  prevented  from  coming  out  in 
their  ])roper  place  for  want  of  room. 

In  the  management  of  second  dentition,  much  will  depend  on 
the  experience  and  judgment  of  the  practitioner.  If  he  be  proper- 
ly informed  upon  the  subject,  and  gives  to  it  the  necessary  care 
and  attention,  the  mouth  will,  in  most  instances,  be  furnished 
with  a  healthful,  well  arranged  and  beautiful  set  of  teeth.  At 
this  time,  "  an  opportunity,"  says  Mr.  Fox,  "presents  itself  for 
eflfecting  this  desirable  object,"  (the  prevention  of  irregularity,) 
"but  every  thing  depends  upon  a  correct  knowledge  of  the  time 
when  a  tooth  requires  to  be  extracted,  and  also  of  the  particular 
tooth,  for  often  more  injury  is  occasioned  by  the  removal  of  a 
tooth  too  early  than  if  it  be  left  a  little  too  long ;  because  a  new 
tooth,  which  has  too  much  room  long  before  it  is  required,  will 
sometimes  take  a  direction  more  difficult  to  alter,  than  a  slight 
irregularity  occasioned  by  an  obstruction  of  short  duration." 

Mr.  Bell  objects  to  the  extraction  of  the  temporary  teeth,  es- 
pecially in  the  lower  jaw,  to  make  room  for  the  permanent,  on 
the  ground  that  the  practice  is  harsh  and  unnatural — that  it 
often  gives  rise  to  a  contraction  of  the  maxillary  arch,  and 
that,  in  consequence  of  the  peduncular  connection  which  exists 
between  the  necks  of  the  temporary  teeth  and  the  sacs  of  the 
permanent  ones,  it  interferes  with  the  uniform  deposition  of  the 
enamel. 

These  objections,  if  they  were  well  founded,  should  deter  evtrj 
dentist  from  adopting  the  practice ;  except  as  a  dernier  resort, 
as  the  lesser  of  two  evils.  But  when  the  temporary  teeth,  by 
remaining  too  long,  are  likely  to  aflfect  the  arrangement,  and, 
consequently,  the  health  of  the  permanent  teeth,  they  should  be 


1 


METHOD   OF   DIRECTING    SECOND    DENTITION.  141 

extracted  ;  because,  in  that  case,  their  presence  is  a  greater  evil 
than  any  that  woukl  be  occasioned  by  their  removal.  As  a  gene- 
ral rule,  they  should  be  suifered  to  remain  until  their  presence  is 
likely  to  injure  the  permanent  teeth  and  their  contiguous  parts. 
The  last  objection  is  founded  upon  a  false  assumption,  but  on 
other  grounds  it  may  often  be  very  properly  urged. 

AVhen  the  permanent  teeth  are  crowded,  the  lateral  pressure 
is  frequently  so  great  as  to  fracture  the  enamel.  If  this  cannot 
be  prevented  in  any  other  way,  one  on  each  side  should  be  ex- 
tracted. It  is  better  to  sacrifice  tAvo  than  permanently  to  en- 
danger the  health  of  the  whole. 

M.  Delabarre,  in  cases  where  the  crowding  is  not  very  great, 
recommends  passing  a  file  between  the  teeth,  as  does  also  Mr. 
Bell,  when  only  the  space  usually  occupied  by  half  of  a  tooth  is 
required. 

Notwithstanding  the  deservedly  high  authority  of  these  two 
gentlemen,  the  author's  experience  compels  him  to  condemn  the 
latter  practice.  The  apertures  thus  formed  soon  close,  but  not 
so  perfectly  as  to  prevent  small  particles  of  extraneous  matter 
from  lodging  between  the  teeth,  and  being  retained  there  until 
they  become  putrid,  vitiating  the  mucous  and  salivary  secretions 
of  the  mouth,  and  thus  causing  the  teeth  to  decay.  In  this  man- 
ner, he  has  sometimes  known  the  front  teeth  to  be  entirely  de- 
stroyed ;  and  he  has  always  observed,  that  teeth  which  had  been 
thus  filed,  were  invariably  the  first,  and  sometimes  the  only  ones, 
to  decay — thus  clearly  pointing  out  the  pernicious  tendency  of 
the  practice. 

He  does  not,  however,  wish  to  be  understood  as  conveying  the 
idea  that  filing  the  teeth  necessarily  causes  them  to  decay,  for, 
when  the  file  is  used  for  any  other  purpose  than  to  gain  room, 
the  apertures  may  be  made  large  enough  to  prevent  the  approxi- 
mation of  the  organs,  and  thus  the  bad  effects  resulting  from  the 
operation  will  be  prevented. 

The  file  should  never  be  used,  therefore,  with  a  view  to  remedy 
irregularity  ;  the  extraction  of  two  teeth,  one  on  each  side  of  the 
jaw,  however  small  the  space  required  to  be  gained  may  be,  is 
far  preferable.  The  second  bicuspids,  cceteris  paribus,  should 
always  be  removed  rather  than  the  first,  but  sometimes  the  ex- 
traction of  the  first  becomes  necessary. 


142  METHOD    OF   DIRECTING   SECOND    DENTITION. 

By  the  removal  of  two  teeth,  ample  room  will  be  gained  for 
the  arrangement  of  all  the  remaining  ones,  and  the  injury  re- 
sulting from  a  crowded  condition  of  the  organs  prevented. 

On  filing  teeth,  to  prevent  irregularity.  Dr.  Fitch  judiciously 
remarks :  "  I  consider  the  expediency  of  filing  or  not  filing  the 
teeth,  ought  to  be  a  subject  of  serious  deliberation  on  the  part 
of  the  dental  practitioner,  never,  especially  in  young  persons, 
performing  the  operation,  unless  obliged  to  do  so,  to  cure 
actual  disease.  I  was  greatly  surprised,  therefore,  in  the  late 
work  of  Mr.  Bell,  to  see  directions  to  file  slightly  irregular  and 
crooked  teeth,  so  as  to  gain  the  room  of  about  half  a  tooth." 

Nature,  when  permitted  to  proceed  with  her  work  without 
interruption,  is  able  to  perform  her  operations  in  a  perfect  and 
harmonious  manner.  But  the  functional  operations  of  all  the 
parts  of  the  body  are  liable  to  be  disturbed  from  an  almost  in- 
numerable number  and  variety  of  causes,  and  impairment  of  one 
organ  often  gives  rise  to  derangement  of  the  whole  organism. 
For  the  relief  of  which,  the  interposition  of  art  not  unfrequently 
becomes  necessary,  and  it  is  fortunate  for  the  well  being  of  man, 
that  it  can,  in  so  many  instances,  be  applied  with  success. 

In  sound  and  healthy  constitutions,  the  services  of  the  dentist 
are  seldom  required  to  assist  or  direct  second  dentition.  In 
remarking  upon  this  subject,  Dr.  Koecker  observes,  "  that  the 
children,  for  whom  the  assistance  of  the  dentist  is  most  fre- 
quently sought,  are  those  who  are  either  in  a  delicate,  or  at  least 
in  imperfect  constitutional  health ;  in  whom  the  state  not  only 
of  the  temporary  teeth,  but  of  the  permanent  also,  is  to  be  con- 
sidered ;  and,  where  both  are  found  diseased,  the  future  health 
and  regularity  of  the  latter  require  the  greatest  consideration  of 
the  surgeon. 

"  Irregularity  of  the  teeth  is  one  of  their  chief  predisposing 
causes  of  disease,  and  never  fails,  even  in  the  most  healthy  con- 
stitutions, to  destroy,  sooner  or  later,  the  strongest  and  best  set 
of  teeth,  unless  properly  attended  to.  It  is  thus  not  only  a  most 
powerful  cause  of  destruction  to  the  health  and  beauty  of  the 
teeth,  but  also  to  the  regularity  and  pleasing  symmetry  of  the 
features  of  the  face :  always  producing,  though  slowly  and  gradu- 
ally, some  irregularity,  and  not  unfrequently  the  most  surprising 
and  disgusting  appearance." 


METHOD    OF   DIRECTING    SECOND    DENTITION.  143 

Finally,  we  would  remark,  that  though  nature  is  generally 
able  to  accomplish  the  task  assigned  her ;  yet  there  are  times 
when  she  requires  aid,  and  it  is  then,  and  then  only,  that  the 
services  of  the  dentist  are  needed.  Therefore,  whilst,  on  the 
one  hand,  we  should  guard  against  any  uncalled  for  interference, 
we  should,  on  the  other,  always  be  ready  to  give  such  assistance, 
as  the  nature  of  the  disturbance  presented  to  our  notice,  may 
require. 


CHAPTER     TWELFTH. 
IRREGULARITY  OF  THE  TEETH. 

The  temporary  teeth  seldom  deviate  from  their  proper  place 
in  the  alveolar  arch ;  but  irregularity  of  arrangement  is  of  fre- 
quent occurrence  in  the  permanent  teeth,  especially  the  cuspids 
and  incisors.  The  first  and  second  molars  are  seldom  irregular ; 
for,  like  the  teeth  of  first  dentition,  they  rarely  encounter  ob- 
struction in  their  growth  and  eruption.  The  first  molars  being 
the  first  of  the  permanent  set  to  appear,  the  ten  anterior  teeth  are 
limited  to  that  part  of  the  arch  occupied  by  the  ten  milk  teeth : 
if  this  space  is  too  small,  irregularity  must  of  necessity  ensue. 

The  dentes  sapientiae  are  sometimes  irregularly  erupted  in  con- 
sequence of  a  want  of  correspondence  between  the  developement 
of  the  tooth  and  the  growth  of  the  maxilla.  The  tooth  in  such 
case  takes  usually  the  direction  of  least  resistance,  the  crown 
presenting  more  or  less  obliquely  forward,  backward,  outward  or 
inward.  Of  these  four  positions,  the  first  and  fourth  are  found 
usually  in  the  lower  jaw  ;  the  second  and  third  are  most  common 
in  the  upper  jaw. 

When  a  bicuspid  is  forced  from  its  proper  place,  it  turns  in- 
ward toward  the  tongue,  or  outward  toward  the  cheek,  accord- 
ingly as  it  is  in  the  upper  or  lower  jaw.  The  cuspids,  when 
prevented  from  coming  out  in  their  proper  place,  make  their 
appearance  cither  before  or  behind  the  other  teeth.  When  they 
come  out  anteriorly,  which  they  do  more  frequently  than  pos- 
teriorly, they  often  become  a  source  of  annoyance  to  the  upper 
lip,  excoriating  and  sometimes  ulcerating  the  mucous  membrane. 

The  incisors  of  the  upper  jaw  present  a  greater  variety  of 
abnormal  arrangement  than  any  of  the  other  teeth.  The  centrals 
come  out  sometimes  before  and  sometimes  behind  the  arch ;  at 
other  times,  their  median  sides  are  turned  either  directly  or 
obliquely  forward  towards  the  lip.  The  laterals  sometimes 
appear  half  an  inch  behind  the  arch,  looking  towards  the  roof  of 


IRREGULARITY   OF   THE   TEETH.  145 

the  mouth ;  at  other  times,  they  come  out  in  front  of  the  arch, 
and  at  other  times  again,  they  are  turned  obliquely  or  trans- 
versely across  it. 

When  any  of  the  upper  incisors  are  very  much  inclined  to- 
ward the  interior  of  the  mouth,  the  lower  teeth,  at  each  occlu- 
sion of  the  jaws,  shut  before  them,  and  become  an  obstacle  to 
their  adjustment.  This  is  a  difficult  kind  of  irregularity  to 
remedy,  and  often  interferes  with  the  lateral  motions  of  the  jaw. 

The  lower  incisors  sometimes  shut  in  this  manner  even  when 
there  is  no  inward  deviation  of  the  upper  teeth.  In  this  case, 
the  irregularity  is  owing  to  preternatural  elongation  of  the  lower 
jaw,  which  arises  more  frequently  from  some  fiiult  of  dentition, 
than  from  any  congenital  defect  in  the  jaw  itself. 

Sometimes,  the  superior  maxillary  arch  is  so  much  contracted, 
and  the  front  teeth  in  consequence  so  prominent,  that  the  upper 
lip  is  prevented  from  covering  them.  Cases  of  tMs  kind,  how- 
ever, are  rarely  met  with ;  but  when  they  do  occur,  it  occasions 
much  deformity  of  the  face,  and  forms  a  species  of  irregularity 
very  difficult  to  correct.  From  the  same  cause,  the  lateral  in- 
cisors are  sometimes  forced  from  the  arch,  and  appear  behind 
the  centrals  and  cuspids,  the  dental  circle  being  filled  with  the 
other  teeth. 

There  are  many  other  deviations  in  the  arrangement  of  the 
incisors.  Mr.  Fox  mentions  one  that  was  caused  by  the  presence 
of  two  supernumerary  teeth  of  a  conical  form,  situated  partly 
behind  and  partly  between  the  central  incisors,  which,  in  conse- 
quence, were  thrown  forAvard,  while  the  laterals  were  placed  in  a 
line  with  the  supernumeraries.  The  central  incisors,  thougli  half 
an  inch  apart,  formed  one  row,  and  the  laterals  and  supernume- 
raries, another.  Mr.  Fox  says  he  has  seen  three  cases  of  this 
kind.     This  description  of  irregularity  is  rarely  met  with. 

M.  Delabarre  says,  that  cases  of  a  transposition  of  the  germs 
of  the  teeth  occasionally  occur ;  so  that  a  lateral  incisor  takes 
the  place  of  a  central,  and  a  central  the  place  of  the  lateral.  A 
similar  transposition  of  a  cuspid  and  lateral  incisor  is,  also,  some- 
times seen.  Two  cases  of  this  sort  have  fallen  under  the  obser- 
vation of  the  author. 

The  incisors  of  the  lower  jaw,  being  smaller  than  those  of  the 
upper,  and  in  other  respects  less  conspicuous,  do  not  so  plainly 


146  TREATMENT   OF    IRREGULARITY   OF   THE   TEETH. 

show  an  irregularity  in  their  arrangement,  nor  is  the  appearance 
of  an  individual  so  much  affected  by  it.  Still  it  should  be  guarded 
against,  for  such  deviation,  whether  in  the  upper  or  lower  jaw, 
may  prove  injurious  to  the  health  of  the  teeth,  and  to  the  beauty 
of  the  mouth.  Tlie  growth  of  the  inferior  permanent  incisors  is 
sometimes  more  rapid  than  the  destruction  of  the  roots  of  the 
corresponding  temporaries.  In  this  case,  the  former  emerge 
from  the  gums  behind  the  latter,  and  sometimes  so  far  back  as 
greatly  to  annoy  the  tongue  and  interfere  with  enunciation.  At 
other  times,  the  permanent  centrals  are  prevented  from  assuming 
their  proper  place,  because  the  space  left  for  them  by  the  tem- 
poraries is  not  sufficient.  The  irregularity  in  the  former  of  these 
two  cases,  is  greater  than  in  the  latter.  The  same  causes,  in 
like  manner,  affect  the  laterals. 

M.  Delabarre  mentions  a  defect  in  the  natural  conformation 
of  the  jaws,  by  which  the  upper  temporary  incisors  on  one  side 
of  the  median  line  are  thrown  on  the  outside  of  the  lower  teeth, 
while  the  corresponding  teeth,  on  the  other  side  of  the  same  line, 
fall  within.*  The  same  arrangement,  he  says,  maybe  expected, 
unless  previously  remedied  in  the  permanent  teeth.  The  author 
has  met  with  but  two  cases  of  this  sort,  and  the  subjects  of  these 
he  did  not  see  until  after  they  had  reached  maturity. 

TREATMENT. 

Orthodontia,  or  the  treatment  of  irregularity,  should  accord 
with  the  indications  of  nature.  When  the  irregularity  is  neither 
great  nor  complicated,  and  its  causes  are  removed  before  the 
nineteenth  or  twentieth  year,  the  teeth,  without  the  aid  of  art, 
will,  in  most  cases,  assume  their  proper  position.  When,  how- 
ever, the  efforts  of  the  economy  are  unavailing,  recourse  should 
be  had  to  the  dentist,  who  can,  in  most  instances,  bring  the  de- 
viating organs  to  their  proper  position  in  the  arch.  Teeth  in- 
cline to  return  to  their  place  on  the  removal  of  the  cause  of  ir- 
regularity. They  may  be  also  made  to  change  position  under 
the  influence  of  pressure.  The  pressure  must  be  constant ;  it 
must  be  sufficient  to  cause  motion,  yet  not  so  great  as  to  set  up 
destructive  inflammation  ;  lastly,  it  must  be  continued  until  the 
tooth   can  be  kept  in  place  by  antagonism   wdth   the  opposing 

*  Traiti  de  la  Seconde  Dentition,  p.  136. 


TREATMENT  OF  IRREGULARITY  OF  THE  TEETH.     147 

teeth ;  or  in  case  there  is  no  such  antagonism  the  regulating  ap- 
paratus must  be  worn  more  or  less  constantly  for  a  year,  or  even 
longer. 

Teeth  artificially  regulated  change  position  chiefly,  if  not  en- 
tirely, by  the  double  process  of  absorption  from  one  side  of  the 
socket,  followed  by  the  slower  process  of  ossific  deposit  on  the 
opposite  side.  It  is  therefore  essential  to  success  that  the  tooth 
be  retained  in  its  new  position,  either  by  the  other  teeth,  or  by 
mechanical  appliance,  until  such  deposit  is  formed.  Many  cases 
fail  from  a  want  of  persistence  on  the  part  of  patient  or  dentist. 

How  far,  and  in  what  direction  a  tooth  may  be  moved  will  de- 
pend partly  upon  the  position  of  the  apex  of  the  root :  partly 
upon  the  antagonism  of  the  opposing  teeth. 

Cuspids  growing  out  far  up  on  the  alveolar  arch  will  usually 
be  found  to  have  short  and  curved  roots.  The  attempt  to  move 
them  might  cause  the  curved  apex  to  pierce  the  alveolus.  Even 
when  not  curved,  the  fang  is  short  and  the  regulated  tooth  will 
not  possess  that  durability  which  is  characteristic  of  the  cus- 
pids. It  should  always  be  borne  in  mind  that  in  regulating 
teeth  the  crown  is  the  movable  point ;  whilst  the  apex  of  the 
fang  is  the  fixed  point,  and  must  determine  in  great  degree  the 
extent  and  direction  of  motion. 

Again,  the  natural  or  artificial  movement  of  bicuspids  back- 
ward to  make  room  for  front  teeth,  may  be  aided  or  hindered  by 
the  opposing  teeth.  An  upper  bicuspid,  for  instance,  once 
carried  back,  so  that  the  posterior  slope  of  the  lower  bicuspid 
strikes  it,  will  retain  its  position  or  may  be  thrown  even  farther 
back. 

Upper  incisors  striking  inside  the  lower,  or  lower  incisors  un- 
naturally prominent,  may  be  regulated,  and  the  opposing  teeth 
will  tend  to  keep  them  in  their  corrected  position.  But  it  will 
require  long  and  patient  use  of  the  regulating  apparatus  to  keep 
in  place  upper  incisors,  which  project  outward,  or  lower  incisors 
inclining  inward. 

In  deciding  upon  the  removal  or  extraction  of  an  irregular 
tooth,  it  should  not  be  forgotten  that  a  tooth  moved  by  mechani- 
cal appliance,  especially  if  the  change  in  position  is  considerable, 
will  not  prove  as  durable  as  if  no  movement  had  been  necessary. 
Hence  it  may  sometimes  be  advisable  to  extract  irregular  cus- 


148     TREATMENT  OF  IRREGULARITY  OF  THE  TEETH. 

pids  in  cases  where  their  correction  requires  much  change  in 
their  position  and  that  of  the  bicuspids. 

In  a  case  very  recently  presented  to  Prof.  Austen,  the  superior 
arch  was  perfectly  regular  and  closely  filled ;  but  both  cuspids 
had  come  out  above  the  arch.  The  cuspid  fangs  were  normal,  and 
it  seemed  practicable  to  bring  these  teeth  down  into  the  places 
of  the  first  bicuspids.  But  the  four  bicuspids  were  sound,  and 
the  first  bicuspids  gave  very  much  the  appearance  of  the  natural 
arrangement.  Hence,  as  in  point  of  expression,  there  would  be 
no  great  gain,  and  in  point  of  durability,  a  probable  loss,  it  was 
not  thought  advisable  to  subject  the  patient  to  the  tedious  annoy- 
ance of  regulation. 

The  practicability  of  altering  the  position  of  a  tooth,  after  the 
completion  of  its  growth,  was  well  known  to  many  of  the  early 
practitioners.  But  before  the  commencement  of  the  present 
century,  the  principal  object  of  the  dentist  was,  the  insertion  of 
artificial  teeth  ;  orthodontia,  therefore,  met  with  little  attention. 
Fauchard  and  Bourdet  were  among  the  first  to  study  this  branch 
of  dentistry.  They  invented  a  variety  of  fixtures  for  adjusting 
irregular  teeth  ;  but  most  of  these  were  so  awkward  in  their  con- 
struction, and  occasioned  so  much  inconvenience  to  the  patient, 
that  they  were  seldom  employed. 

Mr.  Fox  was  among  the  first  to  give  explicit  directions  for 
remedying  irregularity  of  the  teeth,  and  his  method  of  treatment 
has  formed  the  basis  of  the  established  practice  for  more  than 
fifty  years.  This  long  trial  has  proved  it  to  be  founded  upon 
correct  physiological  principles,  and  much  practical  experience. 

In  describing  the  treatment  of  irregularity,  we  shall  notice  the 
means  by  which  some  of  its  principal  varieties  may  be  remedied  ; 
otherwise,  the  application  of  the  principles  of  treatment  would 
not  be  well  understood,  since  it  must  be  varied  to  suit  each  in- 
dividual case. 

As  a  general  rule,  the  sooner  irregularity  in  the  arrangement 
of  the  teeth  is  remedied  the  better;  for  the  longer  a  tooth  is 
allowed  to  occupy  a  wrong  position,  the  more  difficult  will  be  its 
adjustment.  The  position  of  a  tooth  may  sometimes  be  altered, 
after  the  eighteenth,  twentieth,  or  even  the  thirtieth  year,  but  it 
is  better  not  to  delay  the  application  of  the  proper  means  until 
so  late  a  period.     A  change  of  this  kind  may  be  much  more 


TREATMENT  OF  IRREGULARITY  OF  THE  TEETH.     149 

easily  effected  before  the  several  parts  of  the  osseous  system  have 
reached  their  full  development,  and  while  the  formative  process  is 
in  vigorous  operation,  than  at  a  later  period  of  life.  The  age 
of  the  subject,  therefore,  should  always  govern  the  practitioner 
in  forming  an  opinion  as  to  the  practicability  of  correcting  irre- 
gularity. Previously  to  the  twentieth  year,  the  worst  varieties 
of  irregularity  may,  in  most  cases,  be  successfully  treated. 

The  first  thing  claiming  attention  in  the  treatment,  is  the  re- 
moval of  its  causes.  Whenever,  therefore,  the  presence  of  any 
of  the  temporary  teeth  has  given  a  false  direction  to  one  or 
more  of  the  permanent,  they  should  be  extracted,  and  the  de- 
viating teeth  pressed  several  times  a  day  with  the  finger,  in  the 
direction  they  are  to  be  moved.  •  This,  if  the  irregularity  has 
been  occasioned  by  the  presence  of  a  deciduous  tooth,  will,  gene- 
rally, be  all  that  is  required. 

But  when  it  is  the  result  of  narrowness  of  the  jaw,  either 
natural  or  acquired,  a  permanent  tooth  on  either  side  should  be 
removed,  to  make  room  for  such  as  are  improperly  situated. 
All  the  teeth  being  sound  and  well  formed,  the  second  bicuspids 
are  the  teeth  which  should  be  extracted;  but  if,  as  is  often  the 
case,  the  first  permanent  molars  are  so  much  decayed  as  to  ren- 
der their  preservation  impracticable,  or,  at  least,  doubtful,  these 
teeth  should  be  removed  in  their  stead.  After  the  removal  of 
the  second  bicuspids,  the  first,  usually,  very  soon  fall  back  into 
the  places  which  they  occupied,  and  furnish  ample  room  for  the 
cuspids  and  incisors.  But  if  they  fail  to  do  this,  they  may  be 
gradually  forced  back  by  inserting  wedges  of  wood  or  gum 
elastic  between  them  and  the  cuspids,  or  by  means  of  a  ligature 
of  silk,  or  gum  elastic,  securely  fastened  to  the  first  molar  on 
each  side.  These  should  be  renewed  every  day,  until  the  de- 
sired result  is  produced. 

The  most  frequent  kind  of  irregularity,  resulting  from  nar- 
rowness of  the  jaw,  is  the  prominence  of  the  cuspids.  These 
teeth,  with  the  exception  of  the  second  and  third  molars,  are 
the  last  of  the  teeth  of  second  dentition  to  be  erupted;  conse- 
quently they  are  more  liable  to  be  forced  out  of  the  arch  than 
any  others,  especially  when  ft  is  so  much  contracted  as  to  be  al- 
most entirely  filled  before  they  make  their  appearance.  The 
common  practice  in  such  cases  is  to  remove  the  projecting  teeth. 


160     TREATMENT  OP  IRREGULARITY  OF  THE  TEETH. 

But  as  the  cuspids  contribute  more  than  any  of  the  other  teeth, 
except  the  incisors,  to  the  beauty  of  the  mouth,  and  can,  in  al- 
most every  case,  be  brought  to  their  proper  place,  the  practice  is 
injudicious.  Instead  of  removing  these,  a  bicuspid  should  be 
extracted  from  each  side.  When  the  space  between  the  lateral 
incisor  and  the  first  bicuspid  is  equal  to  one-half  the  width  of 
the  crown  of  the  cuspid,  the  second  bicuspid  should  be  removed, 
but  when  it  is  less,  the  first  should  be  taken  out;  because,  al- 
though the  crown  of  the  latter  may  be  carried  far  enough  back 
after  the  removal  of  the  former,  to  admit  the  crown  of  the  cus- 
pid between  it  and  the  lateral  incisor,  the  root  of  this  tooth  will 
remain  in  front  and  partly  across  the  root  of  the  first  bicuspid ; 
leaving  a  more  or  less  prominent  vertical  ridge  on  the  anterior 
part  of  the  alveolar  border,  which,  to  some  extent  at  least,  acts 
as  an  irritant  to  the  gums  and  periosteum.  '^ 

As  the  incisors  of  the  upper  jaw  are  more  conspicuous  than 
those  of  the  lower,  and  when  well  arranged  contribute  more  to 
the  beauty  of  the  mouth,  their  preservation  and  regularity  are 
of  greater  relative  importance.  Hence,  the  removal  of  a  lateral 
incisor,  when  it  is  situated  behind  the  dental  arch,  as  is  often 
done  with  a  view  to  remedy  the  deformity  produced  by  false  posi- 
tion, is  a  practice  which  cannot  be  too  strongly  deprecated,  pro- 
vided sufficient  space  can  be  made  for  it  between  the  cuspid  and 
central  incisor,  by  the  removal  of  a  bicuspid  from  each  side  of 
the  jaw.  ^  .| 

In  describing  the  treatment  of  irregularity,  we  shall  com- 
mence with  an  incisor  occupying  an  oblique  or  transverse  posi- 
tion across  the  alveolar  ridge ;  so  that  the  cutting  edge  of  the 
tooth,  instead  of  being  in  a  line  with  the  arch,  forms  an  angle 
with  it  of  from  forty  to  ninety  degrees.  This  variety  of  devia- 
tion is  rarely  met  with  in  both  centrals,  but  often  occurs  with 
one.  Some  dentists  have  recommended  in  cases  of  this  sort, 
•when  the  space  between  the  adjoining  central  and  lateral  incisor 
is  equal  to  the  width  of  the  deviating  tooth,  to  turn  the  latter  in 
its  socket  with  a  pair  of  forceps,  or  to  extract  and  immediately 
replace  it  in  its  proper  position.  It  is  scarcely  necessary  to 
say,  that  if  a  tooth  is  extracted  or  turned  in  its  socket,  the  ves- 
sels and  nerves  from  which  it  derives  nourishment  and  vitality 
are  severed ;  hence,  though  its  connection  with  the  alveolus  may 


TREATMENT  OF  IRREGULARITY  OF  THE  TEETH. 


151 


Fig.  53. 


be  partially  re-established,  it  will  be  liable  to  act  as  a  morbid 
irritant,  and  be  subject  to  inflammation  from  comparatively 
slight  causes. 

The  tooth,  however,  may  be  brought  to  its  proper  position, 
without  incurring  the  risk 
of  injury,  by  accurately 
fitting  a  gold  ring  or  band, 
with  knobs  on  the  labial 
and  palatine  sides;  to  each 
of  these  a  ligature  should 
be  attached.  Thus  fasten- 
ed to  the  ring,  each  end 
should  be  carried  back,  one 
on  either  side,  in  front  and 
behind  the  arch,  and  se- 
cured to  the  bicuspids  as 
represented  in  Fig.  53,  so 

as  to  act  constantly  upon  the  irregular  tooth.  The  ligatures 
should  be  renewed  from  day  to  day,  until  the  tooth  assumes  its 
proper  position.  Should  the  space  not  be  sufficient  to  permit 
the  use  of  the  band,  the  method  practiced  by  Mr.  Tomes,  as  shown 
in  Fig.  54,  will  be  found  very  effective.  A  plate  is  fitted  to  the  inside 
of  the  arch,  and  a  band  carried  in 
front  and  soldered  to  projections 
from  the  plate,  which  pass  be- 
tween the  bicuspids.  On  each 
side  of  the  twisted  tooth  a  me- 
tallic dovetail  is  fastened  and 
pieces  of  compressed  wood  in- 
serted into  them.  The  swelling 
of  the  wood  gradually  turns  the 
tooth.  In  a  few  days  the  metal 
sockets  will  require  to  be  changed 

in  position,  and  in  a  few  weeks  the  tooth  may  be  thus  brought 
nearly  or  quite  to  its  natural  place. 

If  the  space  permits,  these  two  methods  may  be  advantage- 
ously combined.  Use  the  plate  as  in  Fig.  54  with  the  inner 
dovetail ;  but  for  the  long  outside  band  substitute  the  band  (Fig. 
53)  around  the  tooth,  with  a  loop  on  the  median  side;  from  this 


Fig.  54. 


15'2     TREATMENT  OF  IRREGULARITY  OF  THE  TEETH. 

pass  an  elastic  ligature  to  a  hook  soldered  on  the  plate.  The 
tooth  is  turned  on  its  axis  by  the  combined  pull  of  the  ligature 
and  thrust  of  the  wood. 

Before  attempting  to  turn  the  deviating  organ,  it  should  be 
ascertained  if  the  aperture  between  the  adjoining  teeth  is  suffi- 
cient to  admit  of  the  operation.  If  not,  it  should  be  increased 
by  the  extraction  of  a  bicuspid  from  each  side  of  the  jaw,  and 
movino-  the  teeth  in  front  of  them  backwards  until  sufficient 
room  is  obtained.  The  time  required  to  do  this  will  vary  from 
three  to  eight  or  ten  weeks,  depending  upon  the  number  of  teeth 
to  be  acted  on,  and  the  age  of  the  patient.  A  sufficient  space 
may  sometimes  be  gained  by  pressing  outward  the  adjoining 
teeth  in  cases  where  they  fall  within  the  normal  curve  of  the 
arch.  This  may  be  done  by  the  expansion  of  wood  or  rubber, 
contained  in  metal  sockets  attached  to  the  plate,  behind  each 
tooth  to  be  moved. 

Narrowness  of  the  alveolar  border  is  a  frequent  cause  of  irre- 
gularity of  the  upper  incisors.  In  this  case,  the  centrals  usually 
project,  though  it  sometimes  happens  that  some  are  in  front  and 
some  behind  the  arch,  producing  great  deformity.  To  remedy 
which,  the  second  bicuspids  should  be  removed,  unless  the  first 
molars  are  so  much  affected  by  caries  as  to  render  their  preser- 
vation doubtful.  In  this  case,  they  should  be  extracted,  in  place 
of  the  second  bicuspids.  If  bicuspids  and  first  molars  are 
sound,  and  the  decision  turns  upon  the  probable  relative  dura- 
bility of  the  teeth,  statistics  decide  very  positively  in  favor  of 

the  bicuspids,  especially  under  the  age 
of  fifteen.  But  the  position  of  the 
first  molar  is  too  far  back  to  permit, 
in  all  cases,  the  full  benefit  of  the 
space  gained  by  its  extraction. 

The  following  case  will  serve  to  illus- 
trate the  means  employed  for  remedy- 
ing this  description  of  deformity.  The 
subject  was  a  young  lady  fifteen  years 
of  age.  Her  teeth  presented  the  ar- 
rangement as  seen  in  Fig.  55. 

The    second   molars  of   the  upper 
jaw  occupied  their  proper  position  in  the  alveolar  arch,  or,  in 


TREATMENT  OF  IRREGULARITY  OF  THE  TEETH. 


153 


other  words,  they  were  a  little  more  than  an  inch  and  a  quarter 
apart;  the  first  molars  were  hardly  an  inch  apart,  and  the  first 
bicuspids  were  still  nearer  to  each  other.  The  cuspids,  except 
that  they  were  pushed  a  little  too  far  forward,  occupied,  very 
nearly,  their  proper  position.  The  right  central  and  left  lateral 
incisors  projected  fully  a  quarter  of  an  inch,  lifting  and  other- 
wise annoying  and  disfiguring  the  upper  lip:  the  left  central 
was  thrown  behind  and  partly  between  the  right  central  and 
left  lateral,  while  the  right  lateral  occupied  a  position  in  a  line 
with  it. 

Without  going  into  a  minute  detail  of  the  method  adopted  for 
preparing  the  appliance  used,  it  will 
be  sufiicient  to  refer  the  reader  to  Fig. 
56.  This  represents  a  plaster  model 
of  the  teeth,  alveolar  border,  palatine 
arch,  and  the  apparatus  for  remedying 
the  deformity.  The  second  bicuspids 
were  first  extracted,  then,  by  means 
of  ligatures  applied  to  the  second  mo- 
lars and  first  bicuspids,  and  made  fast 
to  a  band  of  gold  passing  on  the  out- 
side of  the  arch,  which  were  renewed 
every  day,  these  teeth  were  brought  out  to  their  proper  position 
in  eleven  weeks  ;  this  done,  there  was  a  space  of  nearly  an  eighth 
of  an  inch  between  the  cuspids  and  first  bicuspids  ;  this  was  filled 
up,  by  bringing  back  the  cuspids  with  ligatures.  A  ligature  was 
next  applied  to  the  right  lateral,  passed  through  a  hole  in  the 
gold  band  in  front,  and  made  fast.  In  ten  days  this  tooth  was 
brought  to  its  proper  place.  A  ligature  was  now  attached  to  a 
knob  soldered  on  the  gold  plate  which  had  been  fitted  to  the 
inside  of  the  teeth  and  palatine  arch  for  this  purpose,  and  tied 
tightly  in  front  of  the  projecting  right  central  incisor.  In  about 
three  weeks  this  was  brought  to  a  position  alongside  the  lateral 
incisor  of  the  same  side.  The  left  central  was  then,  in  like 
manner,  brought  forward,  and  the  left  lateral  carried  backward 
to  its  proper  place. 

After  the  deformity  was  corrected,  the  teeth  presented  the 
arrangement  represented  in  Fig.  57,  taken  from  a  plaster  model 
made  from  an  impression  of  the  regulated  teeth.     To  correct  the 
11 


154  TREATMENT    OF   IRREGULARITY    OF    THE    TEETH. 

irregularity  in  this  case,  required,  in  all,  twenty-one  weeks.     If 

all  the  teeth  could  have  been  acted 
upon  at  the  same  time,  the  operation 
might  have  been  accomplished  ii>  a 
shorter  period.  It  was  found  necessary, 
too.  in  consequence  of  the  diseased 
action  in  the  gums,  occasioned  by  the 
apparatus,  to  remove  it  every  eight  or 
ten  days,  and  let  it  remain  off  each 
time  twenty-four  hours.  It  may  be 
proper  also,  to  observe,  that  every  time 
the  ligatures  were  removed,  it  was 
taken  from  the  mouth,  and  the  teeth  thoroughly  cleansed. 

For  moving  a  projecting  incisor  or  cuspid  backwards,  a  gold 
spiral  spring  was  formerly  employed.  It  was  found  to  be  more 
eflBcient  than  a  ligature  of  silk,  inasmuch  as  it  kept  up  a  constant 
traction  upon  the  deviating  tooth.  But  it  is  objectionable  on 
account  of  the  annoyance  it  causes  the  patient.  A  ligature  of 
gum  elastic  is  far  preferable,  and  this  material  is  now  very  gene- 
rally employed  in  the  treatment  of  every  description  of  irregu- 
larity in  Avhich  agencies  of  this  sort  are  required.  The  difficulty 
of  tying  india-rubber  ligatures  is  obviated  by  the  use  of  several 
sizes  of  delicate  elastic  tubing  (French  manufacture),  from  which 
sections  may  be  cut  more  or  less  thick,  according  to  the  required 
length  and  power  of  the  ligature.  Each  strip  becomes  thus  an 
endless  band  which  may  be  readily  passed  from  one  tooth  to 
another  or  to  a  hook  on  the  plate. 

There  are  other  kinds  of  irregularity  of  the  upper  incisors ; 
but  we  shall  only  notice  one,  which,  from  its  peculiar  character, 
is  sometimes  exceedingly  difficult  to  remedy.  It  is,  when  one  or 
more  of  these  teeth  are  placed  so  far  back  in  the  jaw,  that  the 
under  teeth  come  before  it  or  them  at  each  occlusion  of  the 
mouth. 

Of  this  kind,  Mr.  Fox  enumerates  four  varieties :  The  first  is, 
when  one  of  the  central  incisors  is  situated  so  far  back,  that  the 
lower  teeth  shut  over  it,  while  the  other  central  remains  in  its 
proper  place,  as  represented  in  Fig.  58,  which  is  copied  from  his 
work,  as  are  also  those  which  follow. 

The  second  is,  when  both  of  the  centrals  have  come  out  behind 


TREATMENT  OF  IRKEGULARITY  OF  THE  TEETH. 


155 


the  circle  of  the  other  teeth,  and  the  laterals  occupy  their  o\vn 
proper  position,  as  represented  in  Fig.  59. 


Fig.  58. 


Fig.  59. 


The  third  is,  when  the  lateral  incisors  are. thrown  so  far  back, 
that  the  under  teeth  shut  before  them, .while  the  centrals  are  well 
arranged,  as  exhibited  in  Fig.  60. 


Fig.  60. 


Fig.  61. 


The  fourth  is,  when  all  the  incisors  are  placed  so  far  behind 
the  arch  that  the  lower  teeth  shut  before  them,  as  in  Fig.  61. 

He  might  also  have  added  to  these  a  fifth  variety  ;  for  it 
sometimes  happens  that  the  cuspids  of  the  upper  jaw  are  thrown 
80  far  back,  as  to  fall  on*  the  inside  of  the  lower  teeth.  The 
author  has  met  with  several  such  cases. 

Two  things  are  necessary  in  the  treatment  of  the  kind  of  irregu- 
larity just  described:  first,  to  prevent  the  upper  and  lower  teeth 
from  coming  entirely  together,  by  placing  between  them  some 
hard  substance,  so  that  the  overlapping  incisors  may  not  inter- 
fere with  the  necessary  outward  movement.  The  second  is,  the 
application  of  some  fixture  that  will  exert  a  constant  and  steady 
pressure  upon  the  deviating  teeth,  until  they  pass  those  of  the 
lower  jaw. 

For  the  accomplishment  of  this,  various  plans  have  been  pro- 
posed. Duval  recommends  the  application  of  a  grooved  or 
guttered  plate,  and  Catalan  has  invented  an  instrument,  based, 
we  believe,  upon  the  same  principle,  but  much  better  adapted  to 
the  purpose.     We  doubted  the  utility  of  the  inclined  plane  of 


156 


TREATMENT  OF  IRREGULARITY  OF  THE  TEETH. 


Catalan,  until  we  had  employeei  it,  and  found  it  an  effectual  and 
speedy  method  of  moving  deviating  front  teeth  in  the  upper  jaw, 
from  behind  the  dental  circle  to  their  proper  places.  It  acts  with 
great  force,  and  in  the  proper  manner  for  the  accoii^lishment 
of  the  object.  But  this  very  force,  and  the  difficulty  of  control- 
ling it,  make  it  necessary  to  be  careful  in  its  use,  especially  upon 
partially  erupted  teeth.  The  fangs  of  such  teeth  are  in  process 
of  formation  and  of  course  highly  vitalized,  and  are  very  suscep- 
tible to  injury  from  the  shock  of  repeatedly  striking  upon  the 
inclined  plane. 

The   accompanying    cuts,    copied   from    Catalan,   exhibit   the 

manner  in  which  his  inclined 
plane  is  constructed.  The 
one  here  represented,  is  ap- 
plied to  a  case  where  all  the 
upper  incisors  fall  behind  the 
lower  front  teeth.  Its  con- 
struction should  be  varied  to 
suit  the  peculiarity  of  each 
case.  If  but  one  tooth  devi- 
ates, only  one  inclined  plane 
will  be  required.  The  appa- 
ratus should  also  be  so  adapt- 
ed and  secured  to  the  teeth 
as  to  occasion  as  little  incon- 
venience to  the  patient  as 
possible.  The  circular  bar 
or  plate  of  gold,  running 
round  in  front  of  the  teeth, 
should  reach  from  the  first 
molar  on  one  side  to  the  first  molar  on  the  other,  and  the  plate, 
extending  up  from  it  should  cover  the  grinding  surfaces  of  these 
teeth  and  be  long  enough  to  cover  their  lingual  faces  also,  as  the 
whole  fixture  will  thereby  be  rendered  firmer  and  more  secure. 

In  the  application  of  this  principle  for  the  correction  of  irregu- 
larity, the  author  has  been  in  the  habit  of  constructing  the  appa- 
ratus somewhat  differently.  With  a  brass  model  and  zinc  counter- 
model,  he  has  a  plate  of  gold  struck  up  over  all  the  teeth,  when 
practicable,  as  far  back  as  the  first  oi'  second  molar,  completely 


TREATMENT  OF  IRREGULARITY  OF  THE  TEETH. 


15 


encasing  them  and  the  alveohir  ridge.  An  encasement  of  this 
sort  (Fig.  64),  possesses  greater  stability  than  can  he  obtained 
for  an  appliance  like  the  one  represented  in  Figs.  62  and  63. 


Fig.  64. 


In  Fig.  64,  is  seen  a 
representation  of  an  in- 
clined plane  for  bring- 
ing forward  a  central 
incisor  which  had  come 
out  about  a  quarter  of 
an  inch  behind  the  cir- 
cle of  the  other  teeth. 
The  manner  of  the 
action  of  this  instrument 
upon  the  deviating  tooth 
is  shown  in  Fig.  65. 

The  plan  proposed 
by  Delabarre,  as  shown  in  Fig.  t)6,  taken  from  his  treatise  on 
second  dentition,  is  to  pass  silk  ligatures  (a)  around  the  teeth, 
in  such  a  way  that  a  properly  directed  and  steady  pressure  will 
be  exerted  on  such  of  the  teeth  as  are  situated  behind  the 
arch.  To  keep  the  jaws  from  coming  in  contact,  he  recommends 
the  application  of  a  metallic  grate  (/>)  fitted  to  two  of  the  inferior 
molars. 

This  plan  possesses  the  merit  of  simplicity,  and  occasions  lit- 
tle or  no  inconvenience  to  the  patient.  It  will,  however,  some- 
times be  found  not  on h^  inefficient.  Init  also  injurious  in  its  action 
upon  the  teeth  adjacent  to  those  to  l)e  brought  forward.  The 
force  on  the  irregular  teeth,  and  those  against  which  the  liga- 
tures act,  being  equal,  and  in  opposite  directions,  the  latter  will 
be  drawn  back,  while  the  former  are  brought  forward  ;  thus  the 
means  used  for  the  correction  of  one  evil,  will   sometimes  occa- 


158 


TREATMENT    OF    IRREGULARITY    OF    THE    TEETH. 


Fig.  67. 


Fig.  68. 


sion  another.      The  author  has  tried  it,  however,  in  some  cases, 
with  the  most  satisfactory  results. 

Mr.    Fox  recomniends  a  gold   bar  about   the  sixteenth  part 

of  an  incdi  in  ■width,  and  of  propor- 
tionate thickness,  bent  to  suit  the 
curvature  of  the  mouth,  and 
fastened  with  ligatures  to  the 
temporary  molars  of  each  side. 
It  is  pierced  opposite  each  irregu- 
lar tooth  with  two  holes.  The 
teeth  of  the  upper  and  lower  jaw 
are  prevented  from  coming  entirely  together  by  means  of  thin 
blocks  of  ivory,  attached  to  each  end  of  the  bar  by  small  pieces 
of  gold,  and  resting  upon  the  grinding  surfaces  of  the  tempo- 
rary molars.  Fig.  67. 

After  the  instrument  has  been    thus  fastened    to  the  teeth, 

silk  ligatures  are  passed 
round  such  as  are  within 
the  arch,  and  through  the 
hobs  opposite  them,  and 
then  tied  in  a  firm  knot,  on 
the  outside  of  the  bar.  Fig. 
6s. 

The  ligatures  must  be 
renewed  every  three  or 
four  days,  until  the  teeth 
shall  have  come  forward  far  enouo^h  to  strike  in  front  of  those 
that  formerly  shut  before  them,  and  until  they  shall  have 
acquired  a  sufficient  degree  of  firmness  to  prevent  them  from 
returning  to  their  former  position.  As  soon  as  the  teeth  shut 
perpendicularly  upon  each  other,  the  blocks  may  be  removed, 
and  the  bar  alone  retained. 

Since  1830,  many  practitioners,  both  in  England  and  the 
United  States,  have  substituted  caps  of  gold  for  the  blocks  of 
ivory  recommended  by  Mr.  Fox,  and  instead  of  simply  bending 
the  bar,  they  now  swage  it  between  metallic  casts  so  that  all  its 
parts,  except  those  immediately  opposite  the  irregular  teeth, 
may  be  perfectly  adapted  to  the  dental  circle.  The  apparatus, 
with  these  modifications,  is  more  comfortable,  and  less  liable  to 
move  upon  the  teeth. 


TREATMENT  OF  IRREGULARITY  OF  THE  TEETH.     159 

Mr.  Fox  directs,  that  the  blocks  of  ivory  be  pbicetl  upon  the 
temporary  molars ;  but  the  caps  of  gold  now  substituted  are 
entirely  disconnected  from  the  bar,  and  are  often  used  after  the 
moulting  of  these  teeth ;  they  are  then  placed  upon  the  first  per- 
manent molars.  As  the  caps  prevent  the  teeth  from  coming  to- 
gether, mastication,  during  the  time  they  are  worn,  is,  necessarily, 
performed  on  them.  They  should,  therefore,  be  placed  upon  the 
largest  and  strongest  teeth  ;  and  for  this  reason  they  should  be 
applied  to  the  molars. 

The  curved  bar  should  be  washed,  and  the  teeth  cleansed 
every  time  the  ligatures  are  renewed.  If  this  be  neglected,  the 
particles  of  food  that  collect  between  it  and  the  teeth,  will  soon 
become  putrid  and  offensive,  constituting  a  source  of  disease  both 
to  the  gums  and  teeth.  Before  the  bar  is  applied,  it  should  be 
ascertained  whether  there  is  sufficient  space  for  the  deviating 
teeth,  and  if  there  is  not,  room  should  be  made  in  the  manner 
before  described. 

Some  diversity  of  opinion  exists  as  to  the  most  suitable  age 
for  the  correction  of  this  description  of  irregularity.  Mr.  Fox, 
it  would  seem,  preferred  the  period  immediately  previous  to  the 
shedding  of  the  temporary  molars — probably  the  tenth  or  eleventh 
year  after  birth.  Others  think,  that  the  forepart  of  the  dental 
arch  continues  to  expand  until  the  second  denture  is  completed, 
and  that  the  bicuspids  afford  a  better  support  for  the  ends  of  the 
bar  than  any  other  teeth,  and  are  content  to  wait  until  the 
fifteenth  or  even  sixteenth  year.  But,  though  the  arch  does 
sometimes  expand  a  little,  yet  even  when  the  expansion  occurs, 
it  is  generally  so  inconsiderable,  that  little  advantage  can  be  de- 
rived from  it.  Moreover,  the  arch,  instead  of  expanding,  is 
much  more  liable  to  contract  whenever  a  vacancy  occurs  in  the 
dental  circle,  either  by  the  extraction,  or  from  the  improper 
growth  of  one  or  more  of  the  teeth ;  hence,  the  difficulty  is  apt 
to  be  increased  by  delay.  The  evil,  it  is  true,  may  be  remedied 
at  the  fifteenth,  seventeenth,  or  even  eighteenth  year ;  but  it  is 
rarely  advisable  to  defer  it  to  so  late  a  period. 

The  most  that  is  required  in  the  treatment  of  irregularity  of 
the  lower  incisors,  is  to  remove  a  tooth,  and  to  apply  frequent 
pressure  to  the  deviating  organs.  The  lower  incisors  are  less 
conspicuous  than  those  of  the  upper  jaw,  and  the  loss  of  one,  if 
the  others  are  well  arranged,  is  scarcely  perceptible. 


160     TREATMENT  OF  IRREGULARITY  OF  THE  TEETH. 

The  use  of  vulcanite  or  hardened  India  rubber  promises  to  be 
of  great  value  in  the  correction  of  irregularities.  The  peculiar 
manipulations  it  requires  will  be  found  in  another  portion  of  this 
work ;  it  is  only  necessary,  therefore,  in  concluding  this  chapter, 
to  briefly  mention  the  properties  which  fit  it  for  this  important 
branch  of  dental  practice. 

It  admits  of  absolutely  perfect  adaptation  to  the  teeth.  If 
only  a  part  of  the  crowns  of  the  teeth  require  fitting,  a  wax 
impression  will  be  sufficiently  accurate.  But  if  the  gum  and 
undercut  surfaces  of  the  teeth  are  to  be  fitted,  a  plaster  impres- 
sion is  necessary.  Professor  x\usten's  method  of  taking  plaster 
impressions  in  gutta-percha  cups,  will  enable  a  skillful  operator 
to  take  an  accurate  impression  of  any  mouth,  however  irregularly 
the  teeth  may  be  arranged. 

A  closely  fitting  vulcanite  plate  can  be  worn  with  comfort ; 
hence  the  patient  is  not  tempted  to  remove  it.  It  has  no  motion, 
hence  does  not  wear  the  teeth  or  irritate  the  gums.  Its  firmness 
of  adaptation  makes  it  an  excellent  "fixed  point,"  from  which 
to  make  pressui*e  or  traction  in  any  required  direction  upon  the 
irregular  teeth  :  the  counter  pressure,  being  distributed  over  all 
the  regular  teeth,  is  not  felt.  When  it  is  necessary  to  cap  the 
molars,  a  layer  of  varying  thickness  should  be  carried  over  them 
all,  to  prevent  the  soreness  caused  by  mastication  upon  any  one 
tooth. 

Any  variety  of  appliance  njay  be  used  in  connection  with  the 
plate,  that  the  judgment  of  the  operator  suggests,  as  best  adapted 
to  bring  about  the  required  change.  The  plastic  nature  of  the 
crude  material  permits  enlargement  or  extension  in  any  direc- 
tion, without  the  necessity  of  soldering,  as  in  metallic  plates, 
and  with  an  exactness  which  cannot  be  had  in  carving  ivory 
blocks. 

Thus,  prominences  may  be  left  l)ehind  teeth  which  are  to  be 
moved  outwards ;  in  which  may  be  made  dovetails  for  the  inser- 
tion of  compressed  wood ;  slits  or  holes  for  india  rnbber,  which 
makes  more  rapid  pressure  than  the  wood ;  or  holes  for  the  inser- 
tion of  small  screws.  These  screws  may  bear  directly  against  the 
tooth,  and  be  turned  slightly  each  day  or  two.  Or  the  portion 
of  the  plate  next  the  tooth  or  teeth  to  be  moved  may  be  sepa- 
rated with  a  delicate  saw  from  the  plate ;  the  ends  of  the  screw 


TREATMENT  OF  IRREGULARITY  OF  THE  TEETH.     161 

or  screws  playing  into  this,  move  the  tooth  or  teeth  by  a  broad 
bearing,  which  will,  in  certain  cases,  be  better  than  the  point  of 
the  screw. 

Or  a  small  piece  of  vulcanized  rubber  may  be  taken  ;  one  end 
fitting  against  a  molar  or  bicuspid,  and  into  the  other  end  a 
screw  thread  cut  to  receive  a  delicate  screw ;  on  the  head  of  this 
screw  a  second  piece  of  rubber  may  be  fitted  against  the  tooth 
to  be  moved  so  as  to  allow  the  screw  to  be  turned  without 
changing  its  position  on  the  tooth.  This  combination  forms  a 
miniature  jack-screw,  similar  to  those  recommended  some  years 
since  by  Dr.  Dwindle,  and  will  often  be  found  useful.  It  may 
be  used  in  combination  with  the  rubber  plate  by  attaching  one 
end  to  the  plate  instead  of  resting  it  against  a  tooth. 

If  it  is  desired  to  move  a  tooth  by  the  elasticity  of  a  spring, 
this  can  be  made  of  vulcanite ;  one  end  of  it  fitted  tightly  into  a 
groove  cut  in  the  plate,  so  that  the  free  end  shall  bear  with  the 
requisite  force  against  the  tooth.  The  elastic  slip  or  spring  can 
readily  be  bent,  by  means  of  a  warm  burnisher,  so  as  to  press 
with  greater  or  less  force,  as  the  case  may  demand.  Fig.  69, 
taken  from  Mr.  Tomes'  work,  will 
illustrate  one  variety  of  the  appli- 
cation of  springs ;  in  this  case 
pressing  outward  and  laterally  the 
left  central  and  right  lateral  in- 
cisors. This  mode  of  making  pres- 
sure will  be  found  xerj  useful.  It 
acts  steadily,  is  under  control,  and 
does  not  need  renewal  so  often  as 
the  wedges  of  wood  or  rubber. 

Where  ligatures  are  required? 
the  vulcanite  plate  affords  an  easy 
means  of  attaching  them  in  any 
desired  position  ;  passing  them  through  holes  and  tying ;  looping 
them  over  projecting  knobs  of  vulcanite,  or  over  small  metal 
hooks  set  in  the  plate  ;  or  stretching  them  through  slits  sawn  in 
the  plate. 

If  a  band  is  to  be  carried  for  any  purpose  in  front  of  the  arch, 
it  may  be  connected  with  the  plate  on  the  inside  of  the  arch, 
through  any  spaces  occurring  between  the  bicuspids  or  molars ; 


162  TREATiMENT    OF    IRREGULARITY   OF    THE    TEETH. 

if  there  are  no  such  spaces,  or  if  thej  are  to  be  closed  up  in  the 
process  of  regulation,  the  cap  which  is  often  required  to  pass 
over  the  molars  will  connect  the  two.  But  the  outside  band  is 
not  often  necessary.  The  inside  plate  is  less  awkward  to  the 
patient,  it  is  out  of  sight ;  and  almost,  if  not  quite,  every  required 
movement  can  be  obtained  from  it,  even  to  the  exclusion  of  the 
inclined  plane  of  Catalan. 

The  case  described  on  page  152,  Fig.  55,  could  have  been 
advantageously  treated  by  the  use  of  a  vulcanite  plate ;  the 
various  stages  progressing  nearly  at  the  same  time.  The  impres- 
sion in  this  case  to  be  taken  in  plaster;  the  plate  capping  the 
second  molars  ;  first  molars  and  first  bicuspids  carried  outward  by 
wooden  or  elastic  wedges,  or  by  a  double  spring  of  vulcanite, 
fastened  to  the  plate  opposite  each  space  of  the  extracted  second 
bicuspids  ;  the  left  central  and  right  lateral  carried  out  by  wedges 
or  screws ;  the  right  central  and  left  lateral  brought  in  by  liga- 
tures looped  over  hooks  in  the  plate.  At  the  completion  of  the 
work  a  new  impression  to  be  taken,  and  the  plate  worn  until  the 
teeth  become  firmly  set,  passing  a  ligature  around  the  two  out- 
standing teeth,  to  prevent  their  tendency  to  return  to  their  old 
positions ;  the  plate  itself  would  keep  the  others  in  place. 

A  text  book  can  only  give  general  principles  and  illustrate 
them  by  a  few  examples ;  for  the  varieties  of  irregularity  are 
almost  endless.  Their  successful  treatment  demands  a  correct 
knowledge  of  physiological  and  pathological  action  to  know  when 
and  where  to  act ;  a  skillful  hand  and  an  inventive  wit  to  know 
just  what  to  do  and  how  to  do  it. 

In  conclusion,  to  sum  up  briefly — do  not  interfere  where  by 
simple  extraction  the  case  will  correct  itself:  when  teeth  must 
be  moved,  do  it  decidedly,  to  avoid  tedious  delay ;  but  take  care 
not  to  be  so  rapid  as  to  excite  inflammation  :  do  not  move  teeth 
with  deformed  or  defective  fangs  ;  do  not  sacrifice  sound  and 
regular  bicuspids,  to  bring  into  the  arch  teeth  which  will  require 
to  be  moved  through  a  great  space  ;  for  this  movement  materially 
impairs  their  durability ;  lastly,  do  not  attempt  to  bring  teeth  to 
a  position  where  you  cannot  keep  them  until  firm  ossific  deposit 
makes  them  permanent  in  their  new  positions. 


CHAPTER  THIRTEENTH. 

DEFORMITY  FROM   EXCESSIVE   DEVELOPMENT  OF  THE 
TEETH  AND  ALVEOLAR  RIDGE  OF  LOWER  JAW. 


Fig.  70. 


When  the  teeth  of  the  lower  jaw  form  a  larger  arch  than 
those  of  the  upper,  the  incisors  and  cuspids  of  the  former  shut 
in  front  of  those  of  the  latter, 
causing  the  chin  to  project,  and 
otherwise  impairing  the  symme- 
try of  the  face.  Figs.  70  and  71 
present  a  front  and  a  side  view  of 
this  deformity.  It  may  result 
from  a  want  of  correspondence  in 
the  development  of  the  teeth  and 
alveoli  of  the  two  maxillae:  the 
upper  jaw  being  defective  in  size,  whilst  the  lower  jaw  is  natu- 
ral ;  or  the  former  being  natural,  the  latter  may  be  in  excess. 
It  may  also  arise  from  a 
simple  eversion  of  the 
lower  teeth  or  inversion 
of  the  upper. 

TREATMENT. 


Fig.  71. 


The  remedial  indica- 
tions of  the  deformity  in 
question  consist  in  dimin- 
ishing the  size  of  the  den- 
tal arch,  which  is  always 
a  tedious  and  difficult 
operation,  requiring  great  patience  and  perseverance  on  the  part 
of  the  patient,  and  much  mechanical  ingenuity  and  skill  on  the 
part  of  the  dentist.  The  appliances  to  be  employed  have,  of 
necessity,  to  be  more   or  less  complicated,  requiring  the  most 


164 


PROTRUSION  OF  LOWER  FRONT  TEETH. 


perfect  accuracy  of  adaptation  and  neatness  of  execution ;  they 
must  also  be  worn  for  a  long  time,  and,  as  a  natural  consequence, 
are  a  source  of  considerable  annoyance.  The  first  thing  to  be 
done,  is  to  extract  the  first  inferior  bicuspids.  Sufficient  room 
will  thus  be  obtained  for  the  contraction,  which  it  will  be  neces- 
sary to  eifect  in  the  dental  arch,  for  the  accomplishment  of  the 
object.  An  accurate  impression  of  the  teeth  and  alveolar  ridge 
should  be  taken  with  wax,  softened  in  warm  water,  and  from 
this  impression,  a  plaster  model  is  procured,  and  afterwards,  a 
metallic  model  and  counter-model,  in  the  manner  to  be  de- 
scribed in  a  subsequent  chapter. 

This  done,  a  gold   plate  of  the  ordinary  thickness  should  be 
swaged  to  fit   the  first  and   second  molars,  (if  the  second   has 
P      -„  made   its  appearance,  and  if 

not,  the  second  bicuspid  and 
first  molar  on  each  side,)  so 
as  completely  to  incase  these 
teeth.  If  these  caps  are  not 
thick  enough  to  prevent  the 
front  teeth  from  coming  to- 
gether, a  piece  of  gold  plate 
may  be  soldered  on  that  part 
of  each  which  covers  the  grind- 
ing surfaces  of  the  teeth.  Having  proceeded  thus  far,  a  small 
gold  knob  is  soldered  to  the  inner  and  outer  front  corners  of 
both  caps,  and  to  each  of  these  a  ligature  of  silk  or  gum  elastic 
is  attached.  These  ligatures  are  to  be  brought  forward  and  tied 
tightly  around  the  cuspids.  When  thus  adjusted,  the  lower  arch 
will  present  the  appearance  exhibited  in  Fig.  72.  By  this  means 
the  cuspids  may,  in  fifteen  or  twenty  days,  be  taken  back  to  the 
bicuspids.  If  in  their  progress  they  are  not  caj-ried  towards  the 
inner  part  of  the  alveolar  ridge,  the  outer  ligatures  may  be  left 
ofi"  after  a  few  days,  and  the  inner  ones  alone  employed  to  com- 
plete the  remainder  of  the  operation. 

After  the  positions  of  the  cuspids  have  been  thus  changed,  a 
circular  bar  of  gold  should  be  made,  extending  from  one  cap  to 
the  other,  so  as  to  pass  about  a  quarter  of  an  inch  behind  the 
incisors,  and  be  soldered  to  the  inner  side  of  each  cap.  A  hole 
is  to  be   made   through  this  band  behind  each  of  the  incisors, 


PROTRUSION  OF  LOWER  FRONT  TEETH. 


165 


through  which  a  ligature  of  silk  may  be  passed  and  brought  for- 
ward and  tied  tightly  in  front  of  each  tooth.  These  ligatures 
should  be  renewed  every  day  until  the  teeth  are  carried  far 
enough  back  to  strike  on  the  inside  of  the  corresponding  teeth 
in  the  upper  jaw. 

Fig.  73  represents  the  appearance  which  the  lower  jaw  pre- 
sents with  the  last-named  apparatus  upon  it,  and  will  better  con- 
vey an  idea  of  its  construction,  Pj^^  ^3 
the  manner  of  its  application, 
and  its  mode   of  action,  than 
any  description  which  can  be 
given. 

An  appliance  of  this  sort 
may  be  made  to  act  with  great 
efficiency  in  remedying  the  de- 
formity in  question;  but,  in 
its  application,  it  is  necessary 
that  the  caps  be  fitted  with  the  greatest  accuracy  to  the  teeth, 
and  they  should  be  removed  every  day  and  thoroughly  cleansed, 
as  well  as  the  teeth  they  cover.  If  this  precaution  is  neglected, 
the  secretions  of  the  mouth,  which  collect  between  the  gold  caps 
and  teeth,  will  soon  become  acrid  and  corrode  the  latter. 

The  remarks  made  in  the  previous  chapter  upon  the  use  of 
the  vulcanite  are  applicable  here.  Such  a  plate,  for  this  class  of 
cases,  is  readily  made,  and  inflicts  no  injury  upon  teeth  or  gums. 
Elastic,  instead  of  silk,  ligatures  might  be  used,  and  the  retrac- 
tion of  the  incisors  carried  on  simultaneously  with  that  of  the 
cuspids. 


CHAPTER    FOURTEENTH. 
PROTRUSION  OF  THE  LOWER  JAW. 

This  deformity,  altliough  produced  by  a  different  cause  from 
the  one  last  described,  is  similar  to  it,  and  gives  to  the  lower 
part  of  the  face  an  unnatural  and  sometimes  disagreeable  ap- 
pearance. It  also  interferes  with  mastication,  and  of>"en  with 
prehension  and  distinct  utterance.  It  wholly  changes  the  rela- 
tionship which  the  teeth  should  sustain  to  each  other  when  the 
mouth  is  closed.  The  cusps  or  protuberances  of  the  bicuspids 
and  molars  of  one  jaw,  instead  of  fitting  into  the  depressions  of 
the  corresponding  teeth  of  the  other,  often  strike  their  most 
prominent  points ;  at  other  times  the  outer  protuberances  of  the 
lower  molars  and  bicuspids,  instead  of  fitting  into  the  depres- 
sions of  the  same  class  of  teeth  in  the  upper  jaw,  shut  on  the 
outside  of  these  teeth.  The  trituration  of  aliments  is  conse- 
quently rendered  more  or  less  imperfect. 

This  protrusion  of  the  lower  jaw  is  supposed  by  some  to  be 
the  result  of  a  '"natural  partial  luxation."  In  fact,  its  causes 
are  by  no  means  clearly  understood.  It  is  often  hereditary,  and 
would  seem  to  be  caused  by  that  mysterious  agency  which  im- 
presses peculiarities  of  growtli  and  shape,  not  only  upon  the 
lower  maxilla,  but  upon  every  bone  in  the  body.  This  agency 
is  so  constant  and  over-ruling,  that  we  must  be  prepared  to  find 
the  jaw  returning  to  its  position  after  the  discontinuance  of 
treatment ;  unless,  by  the  interlocking  of  the  cusps  of  the  upper 
teeth  and  the  overlapping  of  tlie  upper  incisors,  we  can  restrain 
the  tendency.  It  is  of  more  frequent  occurrence  than  the  one 
whicli  results  from  excessive  development  of  the  teeth  and  alve- 
olar ridge,  and  requires,  as  before  stated,  an  entirely  different 
plan  of  treatment.  It  rarely  occurs  previously  to  second  den- 
tition. 

TREATMENT. 
The  plan  of  treatment  usually  adopted,  consists  in  fastening 
on  each  side  a  small  block  of  ivory  or  a  cap  of  vulcanite  on  one 


PROTRUSION   OF   LOWER   JAW.  167 

of  tlie  lower  molars,  thick  enough  to  keep  the  front  teeth  about 
a  quarter  of  an  inch  apart  when  the  jaws  are  closed.  Fox's 
bandage  must  now  be  applied.  This  is  buckled  as  tightly  as  the 
patient  can  bear  with  convenience,  pressing  the  chin  upward 
and  backward.  A  piece  of  tough  wood,  slightly  hollowed  so  as 
to  fit  the  arch  of  the  lower  teeth,  made  narrow  at  the  upper 
end,  is  introduced  between  the  teeth  several  times  a  day,  the 
concave  portion  resting  upon  the  outside  of  the  lower,  and 
against  the  inside  of  the  upper,  employing  at  each  time  as  much 
pressure  as  can  be  safely  applied.  By  continuing  this  operation 
from  day  to  day,  for  several  weeks,  the  natural  relationship  of 
the  jaws  will,  in  most  cases,  be  restored.* 

The  description  of  bandage  here  alluded  to,  and  the  manner 
of  its  application,  is  represented 
in  Fig.  74.  When  the  protru- 
sion of  the  lower  jaw  is  accom- 
panied by  irregularity,  means 
should,  at  the  same  time,  be 
employed  for  remedying  it. 
The  earlier  the  treatment  is  in- 
stituted, the  more  easily  will 
the  deformity  be  overcome.  It 
may,  however,  be  successfully 
remedied  at  any  time  previously 
to  the  twentieth  year  of  age, 
and  sometimes  at  a  much  later 
period;  but  after  this  time  the  operation  becomes  more  difficult. 
In  cases  where  the  lower  front  teeth  close  over  the  upper, 
and  thus  cause  a  deformity  of  the  face,  it  is  important  to  discri- 
minate correctly  between  those  which  result  from  malformation, 
and  a  protrusion  of  the  jaw  occasioned  by  partial  luxation,  as 
the  remedial  indications  in  the  two  are  entirely  different.  Those 
which  would  prove  successful  in  the  one,  would  prove  unsuccess- 
ful in  the  other.  But,  fortunately,  deformity  arising  from  the 
last  mentioned  cause  is,  comparatively,  of  rare  occurrence ;  hence 
the  dentist  is  seldom  called  upon  to  exercise  his  ingenuity  and 
skill  in  its  treatment. 

*  An  interesting  article  by  Dr.  J.  S.  Giinnell,  on  the  treatment  of  deformities  of 
this  kind,  is  contained  in  one  of  the  early  volumes  of  the  American  Journal  of  Dental 
Science. 


CHAPTER    FIFTEENTH. 

PECULIARITIES  IX  THE  FORMATION  AND  GROWTH  OF 
THE  TEETH. 

In  the  development  and  growth  of  the  various  parts  of  the 
body,  curious  and  interesting  anomalies  are  sometimes  observed, 
but  in  no  portion  of  it  are  they  more  frequent  in  their  occur- 
rence or  diversified  in  their  character  than  in  the  teeth.  But 
aberrations  in  the  formation  and  growth  of  these  organs,  are,  for 
the  most  part,  confined  to  the  teeth  of  second  dentition. 

Mr.  Fox  gives  a  drawing  of  a  tooth  very  nearly  resembling 
the  letter  S.  The  malformation  was  caused  by  an  obstructing 
temporary  tooth.  The  author  has  also  met  with  several  exam- 
ples of  teeth  similarly  deformed,  and  from  like  causes. 

The  molars  of  the  upper  jaw  sometimes  have  four  and  even 
five  roots,  and  those  of  the  lower,  three,  and  occasionally  four. 
The  crowns  of  the  teeth,  also,  frequently  present  deviations  from 
the  natural  shape  equally  striking  and  remarkable. 

The  next  peculiarity  to  be  noticed  is  that  of  size,  and  in  this 
respect  the  teeth  are  very  variable.  Even  in  the  same  mouth, 
the  want  of  relative  proportion  between  the  difi'erent  classes  of 
teeth  is  sometimes  quite  conspicuous.  But  examples  of  this  kind 
are  not  very  frequent,  for  where  there  is  an  increase  or  diminu- 
tion in  the  size  of  the  teeth  of  one  class,  there  is  generally  a 
corresponding  change  in  that  of  the  other. 

Aberrations  of  this  character  are  probably  dependent  upon 
some  diathesis  of  the  general  system,  whereby  the  teeth,  during 
the  earlier  stages  of  their  formation,  are  supplied  with  an  exces- 
sive or  diminished  quantity  of  nutriment. 

Some  very  remarkable  deviations  have  been  known  to  take 
place  in  the  growth  of  the  teeth.  The  most  singular  case  on 
record,  is  that  narrated  by  Albinus:  "Two  teeth,"  says  he, 
*'  between  the  nose  and  the  orbits  of  the  eye,  one  on  the  right 
side  and  the  other  on  the  left,  were  enclosed  in  the  roots  of 


PECULIARITIES    OF   THE   TEETH.  169 

those  processes  that  extend  from  the  maxillary  bones  to  the 
eminence  of  the  nose.  They  were  large,  remarkably  thick,  and 
so  very  like  the  canines,  that  they  seemed  to  be  these  teeth,  which 
had  not  before  appeared ;  but  the  canines  themselves  were  also 
present,  more  than  usually  small  and  short,  and  placed  in  their 
proper  sockets.  The  former,  therefore,  appear  to  have  been  new 
canines,  which  had  not  penetrated  their  sockets,  because  they 
were  situated  where  these  same  teeth  are  usually  observed  to  be 
in  children.  But  what  is  still  more  remarkable,  their  points 
were  directed  towards  the  eyes,  as  if  they  were  the  new  eye  teeth 
inverted.  And  they  were  also  so  formed,  that  they  were,  con- 
trary to  what  usually  happens,  convex  on  the  posterior,  and 
concave  on  the  anterior."*  A  case  of  a  somewhat  similar  cha- 
racter is  mentioned  by  Mr.  John  Hunter. 

The  following  case  is  in  the  words  of  Mr.  G.  Wait:  "While 
I  was  prosecuting  my  anatomical  studies,  I  was  struck  with  the 
appearance  of  a  cuspid  of  the  upper  jaw;  it  was  short,  and 
appeared  as  if  the  body  of  the  tooth  was  in  the  jaw,  and  that  it 
was  the  tip  of  the  root  that  presented  itself.  Upon  further 
examination,  I  found  this  verified ;  and  after  the  cranium  and 
lower  jaw  were  properly  macerated  and  cleansed,  I  found  one 
of  the  lower  bicuspids  in  the  same  position." 

The  author  can  readily  imagine  that  a  cuspid  of  the  upper 
jaw  might,  while  in  a  rudimentary  state,  by  some  false  or  un- 
natural attachment  of  the  dental  sac,  be  so  altered  in  its  position, 
as  to  pass  up,  in  its  growth,  between  the  nose  and  orbit.  But 
that  the  crown,  after  having  been  thus  turned  round  in  the 
socket,  should  remain  stationary,  while  the  fang  passed  down 
and  appeared  outside  of  the  gum,  is  a  most  extraordinary  and 
remarkable  anomalism.  In  the  former  instance,  the  tooth  might 
still  continue  to  derive  the  nutriment  necessary  for  its  vitality 
from  the  dental  vessels ;  but  in  the  latter  case,  it  could  not  be 

*  "  Denies  duo  inter  nasum  et  orbes  oculorum,  dexter  sinistcrque,  inclusi  in  radi- 
cibus  processuum  quibus  ossa  maxillaria  ad  eminentem  nasum  pertinent.  Longi 
sunt,  crassitudinis  insignis.  Similes  maxime  caninis,  ut  videri  possint  illi  ipsi  esse, 
non  nati.  At  aderant  praiterea  canini  prater  consuetudinem  parvi,  et  breves,  suis 
mfixi  alveolis.  Itaque  videantur  esse  eanini  novi  qui  non  eruperint,  uptote  ibi  loci 
collocati,  ubi  sunt  novi  illi  in  infantibus.  Sed  quod  miremur,  sursum  divecti,  tan- 
qnam  si  sint  canini  novi  inversi.  Et  ii  quoque  formati  sunt  ut,  contra  quam  alii,  a 
posteriore  parte  gibbi,  ab  anteriore  sinuati  sint,"  &c. — Academ.  Anastat.  liber  1,  p.  54. 
12 


170  PECULIARITIES    OF   THE    TEETH. 

SO  nourished  -without  difficulty,  because  the  apex  of  the  root,  the 
place  -where  the  vessels  and  nerves  enter,  was  entirely  outside 
of  the  gum. 

The  following  is  one  of  the  several  cases  of  deviation  in  the 
ffrowth  of  the  teeth,  that  have  come  under  the  author's  observa- 
tion :  In  1840,  he  was  requested  to  extract  a  tooth  for  a  lady  of 
Baltimore,  under  the  following  circumstances.  She  had,  for  a 
time,  experienced  a  great  deal  of  pain  in  her  upper  jaw,  and 
supposed  it  to  originate  from  the  second  molar  of  the  right  side, 
but  which  Avas  perfectly  sound.  Meanwhile  her  general  health 
became  impaired,  and  her  attending  physician,  thinking  that  the 
local  irritation  might  have  contributed  to  her  debility,  advised 
the  extraction  of  the  tooth.  On  removing  it,  the  cause  of  the 
pain  at  once  became  apparent.  The  dens  sapientiae,  which  bad 
not  hitherto  appeared,  was  discovered  Avith  its  fangs  extending 
back  to  the  utmost  verge  of  the  angle  of  the  jaw ;  while  its 
grinding  surface  had  been  in  contact  with  the  posterior  surface 
of  the  crown  and  neck  of  the  tooth  just  extracted.  On  the  re- 
moval of  the  wisdom  tooth,  the  pain  ceased. 

About  the  middle  of  December,  1849,  a  youth  aged  sixteen, 
applied  to  the  author  to  extract  a  right  superior  bicuspid,  which, 
he  said,  was  ulcerated  at  the  root.  On  examining  his  mouth,  he 
discovered  only  one  bicuspid,  but  above  and  between  the  root  of 
this  and  that  of  the  first  molar,  he  observed  a  small  fistulous 
opening.  On  introducing  a  small  probe,  it  immediately  came  in 
contact  with  the  crown  of  a  tooth  looking  towards  the  malar 
process  of  the  superior  maxillary,  which,  on  extraction,  proved 
to  be  the  second  bicuspid. 

The  author  has  in  his  possession  several  molar  and  bicuspid 
teeth,  which  have  small  nodes  upon  their  necks,  covered  with 
enamel ;  and  there  is  a  jaw  in  the  Museum  of  the  Baltimore 
Dental  College,  which  has  five  teeth  presenting  this  anomaly. 

The  author  has  two  teeth  in  his  possession,  of  most  singular 
shape,  presented  to  him  by  his  brother,  the  late  Dr.  John  Harris. 
They  were  extracted  in  July,  1822,  from  the  right  side  of  the 
upper  jaw  of  a  young  gentleman,  nineteen  years  of  age,  by  the 
name  of  Crawford.  They  occupied  the  place  of  the  first  and 
second  bicuspids,  and  their  crowns  are  almost  wholly  imbedded 
in  lamellated  dentine,  that  should  have  constituted  their  roots, 


PECULIARITIES    OF   THE   TEETH.  171 

but  which  are  entirely  wanting.  Judging  from  their  appearance, 
one  would  be  inclined  to  suppose,  that  their  sacs  failing  to  con- 
tract, they  remained  stationary  in  their  sockets,  and  as  the  base 
of  the  pulps  elongated,  they  came  in  contact  with  the  bottom  of 
the  alveoli  and  were  caused  to  bulge  out  and  to  be  reflected  upon 
their  crowns ;  to  the  enamel  of  which,  nearly  to  their  grinding 
surfaces,  they  are  perfectly  united.  For  some  time  previously 
to  the  extraction  of  these  teeth,  they  had  been  productive  of 
considerable  irritation  and  pain  in  the  gums  and  jaw,  and  it  was 
for  the  relief  of  the  suffering  which  their  presence  induced,  that 
they  were  removed. 

Since  the  publication  of  the  second  edition  of  this  work,  the 
author  has  seen  a  still  more  remarkable  deviation  in  the  growth 
of  a  tooth.  It  is  in  the  upper  jaw  of  an  adult  skull  in  the 
Museum  of  the  Baltimore  Dental  College.  The  natural  teeth 
are  all  well  formed,  and  regularly  arranged  in  the  alveolar 
border,  but  between  the  extremities  of  the  roots  of  the  superior 
central  incisors,  in  the  substance  of  the  jaw,  there  is  a  super- 
numerary tooth,  the  crown  of  which  looks  upward  toward  the 
crest  of  the  nasal  plates  of  the  two  bones.  The  whole  tooth  is 
about  one  inch  in  length,  and  the  apex  of  the  crown  is  nearly  on 
a  level  with  the  floor  of  the  nasal  cavities.  There  is  also  in  the 
museum  of  this  institution  a  central  incisor  of  the  upper  jaw, 
with  the  root  bent  upon,  and  in  contact  with,  the  labial  surface 
of  the  crown.* 

*■  This  tooth  was  presented  to  the  author  by  Dr.  Williams,  dentist,  of  Alexandria,  Va. 


CHAPTER     SIXTEENTH.     • 
OSSEOUS  UNION  OF  THE  TEETH. 

Inclosed  as  each  tooth  is,  in  a  distinct  sac,  and  separated  on 
either  side  by  a  bony  partition,  from  the  adjoining  teeth,  until 
after  the  completion  of  the  formation  of  the  enamel,  it  is  difficult 
to  conceive  how  osseous  union  could  take  place  between  two  of 
these  organs,  and,  we  confess,  that  until  we  actually  witnessed 
an  example  of  it,  which  we  did  for  the  first  time  in  1836,  we 
were  inclined  to  doubt  the  possibility  of  such  an  occurrence. 

During  a  visit  to  the  city  of  Richmond,  Va.,  in  April,  of  the 
above  mentioned  year,  we  had  an  opportunity  of  seeing  two 
cases.  One  consisted  in  the  union  of  the  crowns  of  the  central 
incisors  of  the  upper  jaw,  the  palatine  surface  of  which  presented 
the  appearance  of  one  broad  tooth,  while  anteriorly,  they  had 
the  semblance  of  two  teeth ;  the  other  case  consisted  in  the  union 
of  the  right  central  and  lateral  incisors  of  the  lower  jaw. 

A  professional  friend  in  Virginia  informed  the  author,  in  a 
conversation  some  years  since,  that  he  had  met  with  a  case  of 
osseous  union  between  a  second  bicuspid  and  first  molar  of  the 
lower  jaw,  Avhich  was  so  palpable,  that  there  could  have  been  no 
doubt  of  its  existence. 

Mr.  Fox  has  given  the  drawings  of  four  cases,  the  originals 
of  which,  as  Mr.  Bell  tells  us,  are  still  to  be  seen  in  the  museum 
of  Guy's  Hospital.  Mr.  B.  also  informs  us,  that  he  has  seen 
four  other  examples. 

Dr.  Koecker  is  skeptical  with  regard  to  the  existence  of  osse- 
ous union  of  the  teeth,  and  attributes  to  those  who  assert  that 
they  have  met  with  cases  of  it,  "  a  weak  credulity,  a  love  of  the 
marvelous,  or  a  desire  to  impose  upon  the  world." 

Cases  of  this  sort,  it  is  true,  are  of  rare  occurrence,  and  a 
connection  of  the  fangs  of  two  teeth,  by  an  intervening  portion 
of  the  alveolus,  is  very  easily  mistaken  for  osseous  union  of  the 
roots  themselves.     A  few  years  since,  in  extracting  a  second 


OSSEOUS    UNION    OF    THE    TEETH.  173 

molar  of  the  upper  jaw,  the  author  brought  the  dens  sapientige 
along  with  it.  At  first  he  thought  there  was  osseous  union 
of  the  roots,  but  upon  close  examination,  found  a  very  thin 
portion  ^of  the  alveolar  wall  between,  to  which  their  roots  were 
firmly  attached.  Such  a  case  as  this  would,  in  many  instances, 
be  set  down  as  an  example  of  osseous  union. 

It  is  easy  to  account  for  a  lusus  naturse  of  this  kind,  by  sup- 
posing a  previous  union  of  the  pulps  of  the  two  teeth.  But  from 
the  order  in  which  the  eruption  of  the  teeth  is  effected,  some 
classes  appearing  long  before  others,  it  would,  on  this  suppo- 
sition, seem  that  it  could  only  occur  between  the  central  incisors. 
It  is  not,  however,  thus  limited :  the  central  and  lateral  incisors, 
the  bicuspids,  and  the  molars,  are  sometimes  united. 

An  osseous  union  of  the  teeth  is,  fortunately,  of  rare  occur- 
rence ;  if  it  were  otherwise,  it  would  be  productive  of  many 
accidents  in  the  extraction  of  teeth.  Apart  from  this  considera- 
tion, it  can  be  of  but  little  importance,  either  to  the  practitioner 
or  to  the  physiologist. 

Since  the  publication  of  the  first  edition  of  this  work,  several 
cases  of  osseous  union  of  the  teeth  have  fallen  under  the  obser- 
vation of  the  author,  and  he  now  has  several  specimens  in  his 
anatomical  collection.  He  has  five  examples  of  osseous  union  of 
the  temporary  teeth.* 

The  author  has  more  recently  met  with  several  other  examples 
of  osseous  union  of  temporary  teeth. 

*  For  the  specimens  above  alluded  to,  the  author  is  indebted  to  Dr.  Cassell,  Mr, 
Towusend  and  Dr.  Dwinelle. 


I 


CHAPTER    SEVENTEENTH. 
SUPERNUMERARY  TEETH. 

The  development  of  supernumeraiy  teeth  is  usually  confined 
to  the  anterior  part  of  the  mouth,  and  more  frequently  to  the 
upper  than  to  the  lower  jaw.  They  sometimes,  however,  appear 
as  far  hack  as  the  dentes  sapientijE,  and  Hudson  says,  he  has 
seen  them  behind  these  teeth.  We  have  now  in  our  anatomical 
collection,  two  supernumerary  teeth  that  were  extracted,  one 
from  behind,  and  the  other  at  the  side,  of  one  of  the  upper  wis- 
dom teeth.* 

The  crowns  of  supernumerary  teeth  which  appear  in  the  an- 
terior part  of  the  mouth,  are  usually  of  a  conical  shape,  and  for 
the  most  part,  situated  between  the  central  incisors  ;  they  usually 
have  short,  knotty  roots ;  sometimes,  however,  they  bear  so 
strong  a  resemblance  to  the  other  teeth,  that  it  is  diflScult  to  dis- 
tinguish the  one  from  the  other.  We  once  saw  two  lateral  in- 
cisors in  the  lower  jaw,  both  of  which  were  so  well  arranged,  and 
perfectly  formed,  that  it  was  impossible  to  determine  which  of 
the  two  ought  to  be  considered  as  the  supernumerary.  Mr.  Bell 
mentions  a  case,  in  which  there  were  five  lower  incisors,  all  of 
which  were  well  formed  and  regularly  arranged.  The  author 
has  met  with  several  examples  in  which  supernumerary  teeth  in 
the  lower  jaw  so  closely  resembled  the  natural  incisors,  that  no 
difference  could  be  discerned  between  them.  He  has  also  seen 
examples  of  three  lateral  incisors  in  the  upper  jaw,  where  it  was 
impossible  to  determine  which  was  the  supernumerary. 

Supernumerary  cuspids  rarely  if  ever  occur,  but  supernume- 
rary bicuspids  are  occasionally  met  with.  Delabarre  says,  he 
has  seen  them ;  and  we  have  met  with  three  examples  of  the 
sort ;  in  each  of  these  instances  the  teeth  were  very  small,  not 
being  more  than  one-fourth  as  large  as  the  natural  bicuspids, 
with  oval  crowns,  and  placed  partly  on  the  outside  of  the  circle, 

*  These  teeth  were  removed  by  Dr.  Chewning,  dentist,  of  Fredericksburg,  Va. 


SUPERNUMERARY   TEETH.  175 

and  partly  between  the  bicuspids.  We  extracted  one  of  them, 
and  have  it  still  in  our  possession.  Its  root  is  short,  round,  and 
nearly  as  thick  at  its  extremity  as  it  is  at  the  neck  of  the  tooth. 

The  supernumerary  teeth  that  appear  further  back  than  the 
bicuspids,  though  much  smaller,  bear  a  strong  resemblance  to  the 
dentes  sapientiae. 

Supernumerary  teeth,  although  generally  imperfect  in  their 
formation,  are  less  liable  than  other  teeth  to  decay.  This  may 
be  attributable  to  the  fact,  that  they  are  harder,  and,  conse- 
quently, not  so  susceptible  to  the  action  of  the  causes  that  pro- 
duce the  disease. 

Although  the  occurrence  of  supernumerary  teeth  rarely  dis- 
turbs the  arrangement  of  the  others,  their  presence  is  sometimes 
productive  of  the  worst  kind  of  irregularity  ;  and  even  when  they 
do  not  have  this  effect,  they  impair  the  beauty  of  the  mouth,  and, 
for  this  reason,  should  be  extracted  as  soon  as  their  crowns  have 
completely  emerged  from  the  gums. 

To  the  practitioner  of  dental  surgery,  the  occurrence  of  super- 
numerary teeth  is  interesting,  only  in  so  far  as  it  affects  the 
beauty  of  the  mouth  and  the  relationship  which  the  teeth  of  the 
upper  jaw  sustain  to  those  of  the  lower ;  but  to  the  physiologist, 
it  involves  the  question,  what  determines  their  development? 
In  propounding  this  interrogatory,  however,  it  is  not  our  inten- 
tion to  enter  upon  its  discussion  in  this  place,  as  it  forms  no  part 
of  the  design  of  the  present  treatise. 


CHAPTER    EIGHTEENTH. 
THIRD  DENTITION. 

That  nature  sometimes  makes  an  effort  to  produce  a  third  set 
of  teeth,  is  a  fact  which,  however  much  it  may  be  disputed,  is 
now  so  well  established,  that  no  room  is  left  for  cavil  or  doubt. 

The  following  interesting  particulars  are  taken  from  "  Good's 
Study  of  Medicine:" 

"  We  sometimes,  though  rarely,  meet  with  playful  attempts  on 
the  part  of  nature,  to  reproduce  teeth  at  a  very  late  period  of 
life,  and  after  the  permanent  teeth  have  been  lost  by  accident, 
or  by  natural  decay. 

"  This  most  commonly  takes  place  between  the  sixty-third  and 
eighty-first  year,  or  the  interval  which  fills  up  the  two  grand 
climacteric  years  of  the  Greek  physiologist ;  at  which  period  the 
constitution  appears  occasionally  to  make  an  effort  to  repair  other 
defects  than  lost  teeth.       *       *       * 

"  For  the  most  part,  the  teeth,  in  this  case,  shoot  forth  irregu- 
larly, few  in  number,  and  without  proper  fangs,  and,  even  where 
fangs  are  produced,  without  a  renewal  of  sockets.  Hence,  they 
are  often  loose,  and  frequently  more  injurious  than  useful,  by 
interfering  with  the  uniform  line  of  indurated  and  callous  gums, 
which,  for  many  years  perhaps,  had  been  employed  as  a  substi- 
tute for  the  teeth.  A  case  of  this  kind  is  related  by  Dr.  Bisset, 
of  Knayton,  in  which  the  patient,  a  female  in  her  ninety-eighth 
year,  cut  twelve  molar  teeth,  mostly  in  the  lower  jaw,  four  of 
which  were  thrown  out  soon  afterwards,  while  the  rest,  at  the 
time  of  examination,  were  found  more  or  less  loose. 

"  In  one  instance,  though  not  in  more  than  one,  Mr.  Hunter 
witnessed  the  reproduction  of  a  complete  set  in  both  jaws  appa- 
rently with  a  renewal  of  their  sockets.  '  From  which  circum- 
stance,' says  he,  'and  another  that  sometimes  happens  to  women 
at  this  age,  it  would  appear  that  there  is  some  effort  in  nature  to 
renew  the  body  at  that  time.' 


THIRD    DENTITION.  177 

"The  author  of  this  work  once  attended  a  lady  in  the  country, 
who  cut  several  straggling  teeth  at  the  age  of  seventy-four;  and, 
at  the  same  time,  recovered  such  an  acuteness  of  vision,  as  to 
throw  away  her  spectacles,  which  she  had  made  use  of  for  more 
than  twenty  years,  and  to  be  able  to  read  with  ease  the  smallest 
print  of  the  ncAvspapers.  In  another  case,  that  occurred  to  him, 
a  lady  of  seventy-six,  mother  to  the  late  Henry  Hughes  Eryn, 
printer  of  the  journals  of  the  House  of  Commons,  cut  two  mo- 
lars, and  at  the  same  time  completely  recovered  her  hearing, 
after  having  for  some  years  been  so  deaf  as  to  be  obliged  to  feel 
the  clapper  of  a  small  hand-bell,  which  was  always  kept  by  her, 
in  order  to  determine  whether  it  rung  or  not. 

"The  German  Ephemerides  contain  numerous  examples  of 
the  same  kind ;  in  some  of  which,  teeth  were  produced  at  the 
advanced  age  of  ninety,  a  hundred,  and  even  a  hundred  and 
twenty  years.  One  of  the  most  singular  instances  on  record  is 
that  given  by  Dr.  Slade,  which  occurred  to  his  father;  who,  at 
the  age  of  seventy-five,  reproduced  an  incisor,  lost  twenty-five 
years  before,  so  that,  at  eighty,  he  had  hereby  a  perfect  row  of 
teeth  in  both  jaws.  At  eighty-two,  they  all  dropped  out  succes- 
sively; two  years  afterwards,  they  were  all  successively  re- 
newed, so  that  at  eighty-five,  he  had  once  more  an  entire  set. 
His  hair,  at  the  same  time,  changed  from  a  white  to  a  dark  hue ; 
and  his  constitution  seemed,  in  some  degree,  more  healthy  and 
vigorous.     He  died  suddenly,  at  the  age  of  ninety  or  a  hundred. 

"  Sometimes  these  teeth  are  produced  with  wonderful  rapidity ; 
but  in  such  cases,  with  very  great  pain,  from  the  callosity  of  the 
gums,  through  which  they  have  to  force  themselves.  The  Edin- 
burgh Medical  Commentaries  supply  us  with  an  instance  of  this 
kind.  The  individual  was  in  his  sixty-first  year,  and  altogether 
toothless.  At  this  time,  his  gums  and  jaw-bones  became  pain- 
ful, and  the  pain  was  at  length  excruciating.  But,  within  the 
space  of  twenty-one  days  from  its  commencement,  both  jaws 
were  furnished  with  a  new  set  of  teeth,  complete  in  number." 

A  late  physician  of  Baltimore  informed  the  author  in  1838, 
that  an  example  of  third  dentition  had  come  under  his  own  ob- 
servation. The  subject,  a  female,  at  the  age  of  sixty,  he  as- 
sured him,  erupted  an  entire  set  in  each  jaw. 


178  THIRD    DENTITION. 

The  following  extract  of  a  letter  from  a  professional  friend,* 
describes  another  very  interesting  case. 

"I  have  just  seen  a  case  of  third  dentition.  The  subject  of 
this  'playful  freak  of  nature,'  as  Dr.  Good  styles  it,  is  a  gentle- 
man residing  in  the  neighborhood  of  Coleman's  Mill,  Caroline 
County,  Virginia.  He  is  now  in  his  seventy-eighth  year,  and,  as 
he  playfully  remarked,  'is  just  cutting  his  teeth.'  There  are 
eleven  out,  five  in  the  upper,  and  six  in  the  lower  jaw.  Those 
in  the  upper  jaw  are  two  central  incisors,  one  lateral  and  two 
bicuspids,  on  the  right  side.  Those  in  the  lower  are  the  four 
incisors,  one  cuspid  and  one  molar.  Their  appearance  is  that 
of  bone,  extremely  rough,  without  any  coating  or  enamel,  and 
of  a  dingy  brown  color." 

Two  cases  somewhat  like  the  foregoing,  have  come  under  the 
author's  observation.  The  subject  of  the  first  was  a  shoemaker, 
Mr.  M.,  of  Baltimore,  who  erupted  a  lateral  incisor  and  cus" 
pid  at  the  age  of  thirty.  Two  years  before  this  time,  he  had 
been  badly  salivated,  and,  in  consequence,  lost  four  upper  inci- 
sors and  one  cuspid.  The  alveoli  of  these  teeth  exfoliated,  and, 
at  the  time  he  first  saw  him,  were  entirely  detached  from  the 
jaw  and  barely  retained  in  the  mouth  by  their  adhesion  to  the 
gums.  On  removing  them,  he  found  two  white  bony  protube- 
rances, which,  on  examination,  proved  to  be  the  crowns  of  an  in- 
cisor and  cuspid.  They  were  perfectly  formed,  and  though 
much  shorter  than  the  other  teeth,  yet,  up  to  the  present  time, 
1845,  have  remained  quite  firm  in  the  jaw. 

The  subject  of  the  other  case  was  a  lady,  residing  near  Fred- 
ericksburg, Virginia,  who  erupted  four  right  central  incisors  of 
the  upper  jaw  successively.  One  of  her  temporary  teeth,  in  the 
first  instance,  had  been  permitted  to  remain  too  long  in  the 
mouth,  and  a  permanent  central  incisor,  in  consequence,  came 
out  in  front  of  the  dental  arch.  To  remedy  this  deformity,  the 
deciduous  incisor  was,  after  some  delay,  removed;  and,  about 
two  years  after,  the  permanent  tooth,  not  having  fallen  back  into 
its  proper  place,  was  also  extracted.  Another  two  years  having 
elapsed,  another  tooth  came  out  in  the  same  place  and  in  the 
same  manner,  and,  for  similar  reasons,  was  also  removed.  To 
the  astonishment  of  the  lady  and  her  friends,  a  fourth  incisor 

«  Dr.  J.  D.  McCabe. 


THIRD   DENTITION.  179 

made  its  appearance  in  the  same  place,  two  years  and  a  half 
after  the  extraction  of  the  first  permanent  tooth.  When  it  had 
been  out  about  eighteen  months,  the  author  was  called  in  by  the 
lady,  who  wished  him,  if  possible,  to  adjust  it.  Finding  that  it 
could  not  be  brought  within  the  dental  circle,  he  advised  her  to 
have  it  extracted,  and  an  artificial  tooth  placed  in  the  proper 
place  in  the  arch. 

In  the  second  number  of  the  eighth  volume  of  the  American 
Journal  of  Dental  Science,  the  history  of  a  case  of  four  succes- 
sive dentitions  of  the  upper  central  incisors  is  given.* 

It  is  said  that  the  efforts  made  by  nature,  for  the  production 
of  a  third  complete  set  of  teeth,  are  so  great,  that  they  exhaust 
the  remaining  energies  of  the  system;  and,  as  a  consequence, 
that  occurrences  of  this  kind  are  generally  soon  followed  by 
death. 

The  author  is  not  aware  that  any  attempt  has  ever  been  made 
to  explain  the  manner  of  the  origin  and  formation  of  the  teeth 
of  third  dentition.  The  rudiments  of  the  teeth  of  first  and  se- 
cond dentition  originate  from  mucous  membrane,  while  those  of 
third  dentition  would  seem  to  be  the  product  of  the  periosteal 
tissue  or  bone. 

In  obedience  to  what  law  of  developmental  anatomy  are  the 
teeth  of  third  dentition  formed?  Certainly  not  to  any  one  pri- 
mitively impressed  upon  the  animal  economy,  as  they  have  never 
been  known  to  appear  w'hile  the  teetli  of  second  dentition  remain 
in  the  jaws.  If  the  establishment  of  the  law  which  governs  the 
development  of  a  part,  depends  upon  a  certain  condition  of  other 
contiguous  parts,  it  is  possible  that  the  following  may  be  a  correct 
explanation  of  the  phenomenon  of  third  dentition.  Certain 
parts,  in  certain  states  or  conditions,  and  in  particular  locations, 
perform  functions  peculiar  to  themselves.  In  other  words,  the 
condition  and  location  of  a  part  determines  the  function  or  func- 
tions it  performs.  For  example,  when  the  mucous  membrane 
along  the  course  of  the  alveolar  border  begins  to  assume  a  dupli- 
cated or  grooved  condition,  which  it  does  at  about  the  sixth  week 
of  intra-uterine  existence,  dental  papillae  shoot  up  from  it ;  and 
when,  by  a  similar  duplication  of  this  same  tissue,  behind  the 
sacs  of  the  temporary  teeth,  forming  what  Mr.  Goodsir  styles 

*  Dr.  W.  II.  Dwinelle. 


180  THIRD    DENTITION. 

"cavities  of  reserve,"  the  papillae  of  the  permanent  teeth,  one 
from  the  bottom  or  distal  extremity  of  each  duplication,  begins 
to  be  developed.  Hence,  it  would  seem  that  this  particular  state 
or  condition  of  this  tissue,  and  in  these  particular  locations,  is 
necessary  to  determine  the  development  of  teeth  germs.  This 
arrangement  or  condition  of  mucous  membrane,  in  these  particu- 
lar locations,  which  always  results  from  the  development  of  the 
foetus,  may  be  sometimes  produced  by  accidental  causes,  after  all 
the  organs  of  the  body  have  attained  their  full  size,  or  at  any 
time  during  life ;  and  when  it  does  occur,  it  is  not  unreasonable 
to  suppose  that  a  new  tooth  papilla  should  be  formed.  Proceed- 
ing still  farther,  the  development  of  a  dental  papilla  is  the  sig- 
nal for  the  production  of  a  dental  follicle,  which  ultimately 
becomes  a  sac,  and  then  an  organ  to  supply  the  tooth,  now  con- 
siderably advanced  in  the  process  of  formation,  with  a  covering 
of  enamel.  But  as  the  maxillary  bone  has  previously  attained 
its  full  size,  it  rarely,  if  ever,  happens  that  alveoli  are  formed 
for  these  accidental  productions,  and,  consequently,  they  seldom 
have  roots,  or  if  they  do,  they  are  very  short  and  blunt.  They 
are  usually  connected  with  the  periosteum  of  the  alveolar  border ; 
and  this  union  is  sometimes  so  close  and  intimate,  that  very  con- 
siderable force  is  necessary  for  their  removal,  or  at  least,  so  far 
as  our  own  observations  go  upon  the  subject,  and  we  have  had 
occasion  to  extract  several  in  the  course  of  our  practice.  As  a 
general  rule,  however,  they  become  loose  in  the  course  of  a 
few  years  and  drop  out. 

But  it  may  be  asked,  how  are  such  accidental  duplications  of 
the  mucous  membrane  formed?  This  is  a  question,  we  admit, 
which  it  may  not  be  easy  to  answer  satisfactorily,  but  we  do  not 
think  it  at  all  improbable,  that  they  sometimes  occur  during  the 
curative  process  that  follows  the  removal  of  one  or  more  teeth. 
The  granulated  walls  of  the  gums  surrounding  an  alveolus  from 
which  a  tooth  has  been  extracted,  may  become  covered  with  this 
tissue  before  the  socket  is  filled  with  a  deposit  of  new  bone,  or, 
it  may  cover  the  surfaces  of  the  duplicated  membrane  near 
the  bone ;  and  whenever  such  arrangement  or  condition  of  this 
tissue  takes  place,  upon  the  alveolar  border,  (and  that  it. may, 
occasionally,  we  think  there  can  be  no  question,)  it  is  probable 
that  a  new  tooth  papilla  is  produced,  which,  in  the  progress  of 


THIRD    DENTITION.  181 

its  development,  induces  the  formation  of  the  various  appendages 
necessary  to  the  production  of  a  perfect  tooth. 

This,  in  the  opinion  of  the  author,  is  the  only  way  that  these 
fortuitous  productions  can  be  accounted  for  in  accordance  with 
true  physiological  principles.  It  seems  impossible  to  explain 
the  manner  of  their  formation  in  any  other  way.  All  must 
admit  that  the  presence  of  mucous  membrane  is  necessary,  and 
we  cannot  conceive  of  any  other  way  by  which  its  presence 
beneath  the  general  surface  of  the  gums  can  be  accounted  for; 
but  if  we  admit  this  explanation  to  be  correct,  the  question  is 
at  once  solved.  We  believe  it  is  also  owing  to  the  accidental 
occurrence  of  a  certain  arrangement  or  condition  of  the  mucous 
membrane  concerned  in  the  production  of  the  permanent  teeth, 
consisting,  most  likely,  in  the  formation  of  "  cavities  of  reserve" 
more  than  are  called  for  by  the  teeth  of  this  dentition,  that  the 
development  of  supernumerary  teeth  takes  place. 

The  operations  of  nature,  it  is  true,  are  so  secretly  carried  on, 
that  we  cannot  see  the  precise  modus  operandi  by  which  they  are 
effected ;  yet  in  the  development  of  the  various  organs  and  struc- 
tures of  the  body,  we  may  see  them  at  the  various  stages  of  their 
growth,  and  note  what  precedes  their  arrival  at  these  various 
stages  in  the  progress  of  their  formation,  and  upon  which  their 
accretion  would  seem  to  be  dependent.  The  periods  for  the 
arrival  of  these  stages  of  development,  though  somewhat  irregu- 
lar, occur  for  the  most  part  in  normal  conditions  of  the  body,  at 
certain  fixed  epochs.  Thus,  the  papilla  of  the  first  temporary 
molar  may  usually  be  seen  between  the  sixth  and  seventh  weeks 
of  intra-uterine  existence,  but  previously  to  this  time  a  slight 
groove  or  depression  is  observable  in  the  mucous  membrane  of 
the  part  from  whence  it  has  its  origin.  The  same  is  true  with 
regard  to  the  papillae  of  all  the  other  teeth,  though  the  time  for 
the  commencement  of  their  formation  occurs  at  later  periods. 
The  peculiar  change  which  takes  place  in  the  arrangement  of 
the  mucous  tissue  here,  as  well  as  the  periods  at  which  they 
occur,  are  doubtless  determined  by  certain  stages  in  the  develop- 
ment of  other  parts,  and  these,  very  likely,  may  determine  the 
established  number  of  teeth  in  both  dentitions. 

If  the  foregoing  views  which  we  have  advanced  be  correct, 
these  fortuitous  productions  are  not  the  result  of  a  mere  freak  of 


182  THIRD    DENTITION. 

nature,  as  they  are  sometimes  facetiously  styled.  They  are  the 
result  of  the  operation  of  an  established  law  of  the  economy; 
and  although,  after  the  completion  of  the  teeth  of  second  den- 
tition, its  course  is  suspended,  the  occurrence  of  a  similar  ar- 
rangement or  condition  of  the  mucous  tissue  in  the  parts  in 
question,  will  again  put  it  in  operation. 


PART    SECOND. 


PHYSICAL  CHARACTERISTICS  OF 


THE   HUMAN   TEETH  AND   GUMS, 


J  SALIVARY  CALCULUS, 


THE   LIPS  AND   TONGUE, 


AND    THE    FLUIDS    OF    THE    MOUTH, 


PART  SECOND. 


CHAPTER    FIRST. 

GENERAL  CONSIDERATIONS. 

The  susceptibility  of  the  human  body  to  morbid  impressions 
differs  in  different  individuals.  In  some,  its  functional  opera- 
tions are  liable  to  derangement  from  the  most  trifling  causes  ;  in 
others,  they  are  less  easily  disturbed.  Nor  do  the  same  causes 
always  produce  the  same  results.  Their  effects  are  determined 
by  the  tendency  of  the  organism  and  the  susceptibility  of  the 
part  on  which  they  act ;  both  with  regard  to  constitutional  and 
local  diseases,  this  is  true  of  the  organism  generally  and  of 
all  its  parts  separately  considered,  but  of  none  more  than  the 
teeth,  gums  and  alveolar  processes.  The  teeth  of  some  per- 
sons are  so  susceptible  to  the  action  of  corrosive  agents,  as  to 
become  involved  in  general  and  rapid  decay,  as  soon  as  they 
emerge  from  the  gums ;  while  those  of  others,  though  exposed  to 
the  same  causes,  remain  unaffected  through  life.  A  similar  dif- 
ference of  susceptibility  also  exists  in  the  parts  within  which 
these  organs  are  contained. 

With  the  teeth,  these  differences  of  susceptibility  to  morbid 
impressions,  are  implanted  in  them  at  the  time  of  their  forma- 
tion, and  are  the  result  of  the  different  degrees  of  perfection  in 
which  this  process  is  accomplished.  In  proportion  as  these 
organs  are  perfect,  is  their  capability  of  resisting  the  action  of 
destructive  agents  increased,  and  as  they  are  otherwise,  it  is 
diminished.  This  is  true  of  every  part  of  the  body ;  but  as  the 
teeth  are  formed,  so  they  continue  through  life,  if  not  impaired 
by  disease,  except  that  they  gradually  acquire  a  very  slight  in- 


186  GENERAL   CONSIDERATIONS. 

crease  of  density,  whereby  their  liability  to  caries  is  correspond- 
ingly lessened. 

Not  so,  however,  with  the  other  parts  of  the  body.  They  may 
be  innately  delicate,  or  imperfectly  developed,  and  afterwards 
become  firm  and  strong,  or  be  at  first  healthy  and  well  formed, 
and  subsequently  become  impaired  ;  and  in  proportion  as  they 
undergo  these  changes,  is  their  susceptibility  to  disease  increased 
or  diminished.  But  the  teeth  are  not  governed  by  the  same 
laws,  either  physical  or  vital,  that  regulate  the  operations  of 
the  other  parts  of  the  animal  economy.  Not  only  the  manner 
of  their  formation,  but  their  diseases,  also,  are  difi"erent.  The 
other  tissues  of  the  body,  not  excepting  the  osseous,  are  endowed 
with  recuperative  powers,  whereby  an  injury  is  repaired  by  their 
own  inherent  energies,  but  the  teeth  do  not  possess  such  attri- 
butes. 

Assuming  these  propositions  to  be  true ;  and  that  they  are,  es- 
pecially those  with  regard  to  the  teeth,  we  shall  endeavor  to 
show  ;  it  becomes  an  object  of  considerable  importance  to  discover 
the  signs  by  which  the  susceptibility  of  the  human  organism  to 
disease  may  be  determined.  But  to  do  this,  except  in  so  far  as 
the  teeth,  gums  and  alveolar  processes  are  concerned,  is  not  our 
present  object ;  yet,  in  the  prosecution  of  the  task  we  have  under- 
taken, we  shall  have  occasion  to  advert  to  certain  constitutional 
and  local  tendencies,  indicated  by  the  appearance  and  condition 
of  the  teeth  and  other  parts  of  the  mouth. 

M.  Delabarre  aflSrms,  that  by  an  inspection  of  the  teeth,  we 
can  ascertain  whether  the  innate  constitution  is  good  or  bad,  and 
our  own  observations  go  to  confirm  the  truth  of  this  opinion ;  but, 
as  this  author  adds,  these  are  not  the  only  organs  that  should  be 
interrogated.  The  lips,  the  gums,  the  tongue,  and  the  fluids  of 
the  mouth  should  also  be  examined  to  discover  the  health  of  the 
organism,  and  ascertain  whether  the  original  condition  of  the 
constitution  has  undergone  any  change. 

Those  who  have  not  been  in  the  constant  habit  of  closely  ob- 
serving the  appearances  met  with  in  the  mouth,  may  be  sceptical 
with  regard  to  the  information  that  may  thus  be  derived ;  but 
those  who  have  studied  them  with  care,  will  not  hesitate  to  say, 
that  they  are,  in  many  instances,  more  certain  and  accurate  than 
any  which  can  be  obtained  from  other  physical  appearances. 


GENERAL    CONSIDERATIONS.  187 

For  example — the  periods  of  the  dentinification  of  the  different 
classes  of  both  sets  of  teeth  being  known,  we  are  enabled  to  infer 
whether  the  innate  constitution  be  good  or  bad,  from  the  physical 
condition  of  these  organs ;  for  as  the  functions  of  the  organism 
are  at  this  time  healthily  or  unhealthily  performed,  will  they  be 
perfect  or  imperfect,  or  in  other  words,  will  their  texture  be 
hard  or  soft. 

It  is  well  known  to  writers  on  odontology,  that  the  teeth  of 
the  child,  like  other  parts  of  the  body,  usually  resemble  those  of 
its  parents ;  so  that  when  those  of  the  father  or  mother  are  bad 
or  irregularly  arranged,  a  similar  imperfection  is  generally  found 
to  exist  in  those  of  the  offspring  ;  but  this  does  not  necessaril}^ 
follow,  and  wdien  it  does,  it  is  the  result  of  the  transmission  of 
some  constitutional  impairment,  whereby  the  formative  operation 
of  these  organs  is  either  disturbed  or  prevented  from  being 
effected  in  a  perfect  and  healthy  manner.  The  quality  of  the 
teeth  of  the  child,  therefore,  may  be  said  to  depend  on  the  health 
of  the  mother,  and  the  aliment  from  which  it  derives  its  subsis- 
tence. If  the  mother  be  healthy,  and  the  nourishment  of  the 
child  of  good  quality,  the  teeth  will  be  dense  and  compact  in 
their  texture,  generally  well  formed  and  Avell  arranged,  and  as  a 
consequence  less  liable  to  be  acted  on  by  morbid  secretions  than 
those  of  children  deriving  their  being  from  unhealthy  mothers, 
and  subsisting  upon  aliment  of  a  bad  qualit3^  Temperament, 
also,  exercises  an  influence  upon  the  functional  operations  of  the 
body.  Upon  it  the  constitutional  health  depends  to  a  greater 
extent  than  pathologists  generally  admit,  and  hence  it  is,  that 
that  of  the  child  usually  partakes  of  that  of  one  or  other,  or  both, 
of  its  parents.  "  This,"  says  M.  Delabarre,  "  is  particularly  ob- 
servable in  subjects  that  have  been  suckled  by  a  mother  or  nurse 
whose  temperament  was  similar  to  theirs."  To  obviate  the  en- 
tailment of  this  evil,  he  recommends  mothers,  having  teeth  con- 
stitutionally bad,  to  abstain  from  suckling,  and  that  this  highly 
important  office  be  entrusted  to  a  nurse  having  good  teeth ;  as- 
serting at  the  same  time,  that  by  this  means,  the  transmission  of 
so  troublesome  a  heritage  as  bad  teeth  may  be  avoided. 

Depending,  then,  as  the  physical  condition  of  the  teeth  and 
the  organism  generally,  confessedly  do,  upon  the  quality  of  the 
nourishment  from  ■which  subsistence  is  derived  during  infancy  and 


188  GENERAL   CONSIDERATIONS. 

childhood,  it  is  highly  essential  that  this  be  good ;  and  that  that, 
especially,  derived  from  the  breast,  be  from  those  only  who  are 
in  the  enjoyment  of  perfect  health,  and  possess  good  constitu- 
tions. 

Delabarre  says,  that  a  child,  though  it  derives  its  being  from 
weakly  parents,  may,  by  proper  regimen,  acquire  a  good  consti- 
tion  and  temperament.  M.  Maiion,  a  French  dentist  and  author 
of  considerable  acumen  and  celebrity,  affirms,  that  a  person  can- 
not be  born  with  a  good  constitution,  unless  those  from  Avhom 
he  derives  his  being  are  in  good  health,  and  of  that  age  when 
life  is  vigorous.  But  he  admits,  that  a  child  coming  from  parents 
of  the  most  perfect  health,  may  have  its  constitution  deteriorated 
by  impure  lactation :  and  that  a  child  coming  from  weakly  pa- 
rents, may  acquire  a  good  constitution,  though  it  will  always 
bear  about  it  certain  signs  of  that  which  it  had  inherited ;  and 
thence,  he  deduces  that  it  is  possible  to  discover,  by  an  examina- 
tion of  the  teeth,  any  tendencies  that  may  be  lurking  in  the  system. 
He  has  certainly  studied  the  subject  very  attentively,  and  his 
remarks  are  worthy  of  consideration.  If  all  he  says  is  not  true, 
many  of  his  observations,  we  think,  are  susceptible  of  proof. 

In  treating  upon  the  physiognomical  indications  of  the  teeth, 
the  last  named  author  says  :  "  Does  the  child  derive  its  life  from 
parents  that  are  unhealthy  ?  Then  the  enamel  of  its  milk  teeth 
will  be  bad ;  the  teeth,  themselves,  will  be  impressed  Avith  a 
bluish  tinge,  and  in  a  short  time,  corroded  by  a  humid  and  putre- 
fying caries.  When  the  parents  are  only  weakly  or  delicate,  the 
enamel  of  the  primary  teeth  will  have  a  bluish  appearance,  tliere 
will  be  a  tendency  in  them  to  dry  caries,  which  does  not  ordi- 
narily make  much  progress,  and  seldom  causes  pain," 

Again,  he  observes,  "  It  was  only  by  a  determination  to 
notice  very  accurately  the  diflferences  which  I  remarked  in  the 
teeth  of  numerous  individuals,  that  I  obtained  these  primary 
truths ;  which  in  the  first  instance  were  little  more  than  mere 
conjectures,  but  by  being  daily  increased,  have  now  become 
diagnostics,  about  the  certainty  of  which,  I  flutter  myself,  I  can- 
not be  deceived.  It  affords  me  pleasure  to  give  an  account  in 
this  place  of  a  part  of  the  means  Avhich  I  employed  to  arrive  at 
the  point  which  was  the  object  of  my  researches.  When  I  per- 
ceived some  signs,  as  for  example,  shadowy  lines  on  the  primary 


GENERAL   CONSIDERATIONS.  189 

teeth,  and  those  of  replacement,  of  different  children,  I  put  all 
my  application  to  work  for  the  ascertainment  of  their  cause  ;  and 
when  I  believed  I  had  found  it,  I  interrogated  their  mothers, 
who  generally  confirmed  the  judgment  I  had  formed.  I  then 
went  on  further ;  after  calculations  that  seemed  to  me  highly 
probable,  I  ventured  to  declare  the  period  at  which  a  great 
crisis  or  disease  had  happened,  and  in  such  a  month  of  pregnancy ; 
and  I  have  had  the  satisfaction  to  find  that  I  had  conjectured 
correctly.  My  expectations,  based  upon  the  same  procedure, 
have  been  crowned  with  success  in  adults  ;  whose  teeth,  by  the 
simple  examination  of  them,  have  disclosed  to  me  an  advantage 
no  less  valuable  than  the  first;  namely,  that  of  generally  being 
able  to  tell,  whether  they  were  born  of  strong,  weak,  or  aged 
parents  ;  and  also,  if  the  mother  has  had  several  children, 
whether  they  were  among  the  last,"  etc. 

That  a  person  experienced  in  such  researches,  may,  by  an 
examination  of  the  deciduous  teeth,  tell  whether  the  mother, 
during  the  latter  periods  of  pregnancy,  had  enjoyed  good  or  bad 
health,  there  is  no  question.  But  it  is  very  doubtful  whether 
much  can  be  ascertained,  by  an  inspection  of  the  milk  teeth, 
concerning  the  health  of  the  mother  previously  to  the  time  of 
the  commencement  of  their  solidification,  for  upon  the  manner 
in  which  this  is  effected,  depends  their  appearance  and  physical 
condition.  The  density  of  a  tooth  may  be  told  at  a  single  glance 
by  a  practical  observer,  and  it  is  this  and  its  color  that  are 
principally  influenced  by  the  condition  of  the  system  during  their 
solidification.  The  shape  of  the  teeth  is  determined  by  that  of 
the  jaws  and  pulps  before  the  commencement  of  this  process. 

We  are  of  opinion,  therefore,  that  nothing  positive,  concern- 
ing the  health  of  the  mother  during  the  first  five  or  six  months 
of  pregnancy,  can  be  learned  from  an  inspection  of  the  teeth  of 
either  dentition.  From  an  inspection  of  those  of  the  second, 
no  information  whatever  in  relation  to  it  can  be  derived,  and  if 
Mahon  was  fortunate  enough  in  some  instances  to  tell  what  it 
had  been  at  an  earlier  period,  his  prognosis  could  not  have  been 
founded  upon  any  thing  more  than  mere  conjecture. 

The  teeth  while  in  a  pulpy  state  partake  of  the  health  of  the 
organism  generally.  As  that  is  healthy  and  strong,  or  un- 
healthy and  weak,  so  will  the  elementary  principles  of  which 


190  GENERAL    CONSIDERATIONS. 

they  are  then  eompo.sed,  he  of  a  good  quality,  or  deteriorated  : 
but  after  dentinification  has  commenced,  the  solid  parts  cease  to 
he  influenced  by,  or  to  obey  the  Liws  of  the  other  parts  of  the 
body.  If  the  general  health  be  good  at  the  time  this  process  is 
going  on,  it  will  be  evidenced  in  their  density  and  color ;  if  bad, 
in  the  looseness  of  their  texture,  etc. 

This  is  a  subject  to  which  we  have  paid  some  attention,  having 
for  a  long  time  been  in  the  habit  of  carefully  noting  the  diflFer- 
ences  in  the  appearance  of  the  teeth  of  different  individuals,  and 
of  both  dentitions  ;  and  though  we  have  been  able  to  conjecture 
in  some  instances  what  had  been  the  state  of  the  mother's  health 
during  the  first  months  of  pregnancy,  candor  compels  us  to  con- 
fess, that  we  have  never  been  able  to  find  any  signs  in  the  pecu- 
liarity of  their  sliape,  size,  density,  or  arrangement,  that  indicated 
it.  But  from  the  moment  that  the  part  of  the  formative  process 
of  these  organs,  which  is  not  influenced  by  subsequent  changes  in 
the  general  economy,  commences,  certain  peculiarities  of  appear- 
ance are  impressed  upon  them  that  continue  through  life,  and 
about  the  certainty  of  the  indications  of  which,  in  regard  to  the 
general  health,  we  think  there  can  be  no  doubt. 

In  commenting  upon  the  views  which  M.  Mahon  advances 
upon  this  subject,  Delabarre  says,*  "  if  he  had  thrown  the  light 
of  repeated  dissections  upon  them,  he  would  have  acknowledged, 
with  Hunter,  Blake,  Maury,  Fox  and  Bunon,  that  the  secondary 
teeth  do  not  begin  to  ossify  until  about  the  sixteenth  month  after 
birth,  so  that  the  good  or  bad  health  of  the  parents  at  the  time 
of  conception,  cannot  in  any  way  affect  the  teeth  of  replacement, 
which  are  not  formed  until  after  the  child  comes  into  the  world." 

But,  however  vague  and  erroneous  may  be  some  of  the  opin- 
ions of  Mahon,  he  has  certainly  advanced  many  that  are  correct, 
and  from  which,  hints  have  been  derived  that  have  formed  the 
foundation  of  some  very  valuable  contributions  to  the  science  of 
the  semeiology  of  the  teeth. 

Layater  Avas  laughed  at  and  ridiculed  for  his  enthusiastic 
belief  in  physiognomy  ;  but  the  description  which  he  gives,  with 
a  view  to  the  illustration  of  his  favorite  science,  of  the  physical 
conformation  of  the  various  parts  of  the  face,  head,  and  other 
portions  of  the  organism  of  man,  embrace  signs,  which,  if  applied 

*  Vide  Semeitique  Biiccah,  p.  225. 


GENERAL    CONSIDERATIONS.  191 

to  the  study  of  semeiology,  could  hardly  fail  to  lead  to  important 
results.  Had  the  education  and  pursuits  of  this  good  and  extra- 
ordinary man,  fitted  him  for  the  investigation  of  this  department 
of  medical  science,  and  had  he  entered  into  it  with  the  same  per- 
severing ardor  and  zeal  he  did  that  of  physiognomy,  he  would 
have  erected  for  himself  an  equally  enduring  monument  of  fame, 
and  would  thus  perhaps  have  contributed  as  much  to  the  ameli- 
oration of  the  condition  of  his  fellows,  as  he  has  done  by  his 
physiognomical  researches.  In  fact,  of  the  importance  of  this 
subject,  he  seems  to  have  been  fully  aware;  and,  after  acknow- 
ledging his  ignorance,  he  says,  the  physiognomical  and  pathog- 
nomical  semeiotica  of  health  and  disease  ought  to  be  investigated 
by  an  experienced  physician,  stating,  that  from  the  few  observa- 
tions which  he  had  made,  it  was  not  difficult  to  discover  the  dis- 
eases to  which  an  individual  in  health  is  most  liable.  He  resrards 
physiognomical  semeiotics,  founded  upon  the  nature  and  form  of 
the  body,  as  of  great  importance  to  the  medical  practitioner,  that 
he  may  be  able  to  say  to  an  individual  in  health,  you  may  ex- 
pect this  or  that  disease  some  time  in  your  life.  Possessed  of 
this  knowledge,  he  would  be  able  to  prescribe  the  necessary  pre- 
ventatives or  precautions  against  such  diseases  as  the  patient  is 
most  liable  to  contract. 

Among  the  signs  which  he  notes  as  indicative  of  the  tempera- 
ment, he  enumerates  the  shape,  size  and  arrangement  of  the 
teeth ;  but  from  the  physical  characteristics  of  these  organs, 
when  considered  separately  from  other  parts  of  the  mouth,  we 
only  learn  what  the  innate  constitution  is ;  they  cannot  be  re- 
lied upon  as  indices  to  the  state  of  the  health  subsequent  to  the 
time  of  their  solidification.  Their  own  liability  to  disease,  how- 
ever, may  be  determined  by  their  appearance ;  therefore,  with 
the  signs  indicative  of  this,  every  dentist  should  be  familiar,  so 
as  to  enable  him,  when  consulted  with  regard  to  the  attention 
necessary  to  the  preservation  of  these  organs,  to  prescribe  such 
precautionary  measures  as  will  secure  them  against  the  attacks 
of  disease. 

With  regard,  also,  to  the  information  concerning  the  innate 
constitution,  to  be  derived  from  an  inspection  of  the  teeth,  it  has 
been  well  remarked  by  Delabarre,  that  physicians  may  derive 
much  advantage  in  pointing  out  the  rules  of  domestic  hygiene 


192  GENERAL   CONSIDERATIONS. 

for  the  physical  education  of  children ;  for,  says  this  eminent 
dentist,  "can  he  admit  of  but  one  mode  ?  Has  he  not,  then,  the 
greatest  interest  in  being  well  assured  of  the  innate  constitution 
of  each  child,  for  whom  advice  is  required,  to  enable  him  to  recom- 
mend nutriment  suited  to  the  strength  of  its  organs  ?  Will  he 
report  only  on  a  superficial  examination  of  the  face,  its  paleness, 
the  color  of  the  skin,  all  of  which  are  variable  ?  Will  he  not  re- 
gard the  repletion  or  leanness  of  the  subject,  the  state  of  the 
pulse,  &c.  ?  Surely  he  will  make  good  inductions  from  all  these 
things  ;  but  the  minute  examination  of  the  mouth  will  give  him, 
beyond  doubt,  the  means  of  confirming  his  judgment ;  for,  be- 
sides what  we  already  know  of  the  teeth,  the  mucous  membrane 
of  the  buccal  cavity  receives  its  color  from  the  blood,  and  varies 
according  to  the  state  of  that  fluid."  This  is  a  matter  which  the 
observation  of  the  dentist  has  an  opportunity  of  confirming,  almost 
every  day ;  and  which,  when  taken  in  connection  with  the  phy- 
sical characteristics  of  the  teeth,  together  with  those  of  the  sali- 
vary and  mucous  secretions  of  the  mouth,  constitute  data,  from 
which  both  the  innate  and  present  state  of  the  constitutional 
health  may  be  determined  with  accuracy  and  certainty. 

The  symptoms  of  actual  disease  have  been  minutely  and  re- 
peatedly described,  but  the  physiognomical  signs  by  which  the 
susceptibility  of  the  human  organism  to  morbid  impressions  is 
determined,  and  the  kind  of  malad}^  most  liable  to  result  there- 
from, do  not  appear  to  be  so  well  understood.  "Whatever," 
says  the  author  last  quoted,  "maybe  the  knowledge  which  a 
practitioner  may  acquire  of  the  changes  which  a  disease,  or  even 
any  tendency  to  disease,  may  efi"ect  in  the  functions  of  some 
organs,  it  is,  at  least,  advantageous  to  be  able  to  conjecture  what 
has  happened,  in  the  whole  of  the  system  at  some  other  time. 
In  fact,  can  a  physician,  when  about  to  prescribe  for  a  slight  in- 
disposition of  a  person  whom  he  hardly  knows,  rely  entirely 
upon  the  symptomatology  of  the  tongue?  Does  not  its  aspect 
singularly  vary  ?  Is  it  not  notorious,  that  in  certain  persons  it  is 
always  red,  white,  yellow  or  blackish  ?  I,  as  well  as  others, 
have  had  occasion  to  make  these  observations  on  persons  with 
whom  it  was  always  thus,  yet  without  their  being  subject  to  any 
of  those  indispositions  that  are  so  common  in  the  course  of  life.' 
These  signs  are  as  variable  in  sickness  as  in  health,  and,  conse- 


GENERAL    CONSIDERATIONS.  193 

quently,  can  only  be  relied  upon  as  confirmatory  of  the  correct- 
ness of  other  indications  which  manifest  themselves  in  other 
parts  of  the  body. 

The  physical  changes  produced  by,  and  characteristic  of,  dis- 
ease have  been  described,  both  by  ancient  and  modern  medical 
writers,  but  the  works  which  have  appeared  upon  this  subject  do 
not  comprise  all  that  is  necessary  to  be  known.  For  example — 
if  we  examine  the  lips,  tongue  and  gums  of  a  dozen  or  more  in- 
dividuals who  are  regarded  as  in  health,  differences  in  their  ap- 
pearance and  condition  will  be  found  to  exist.  The  lips  of  some 
will  be  red,  soft  and  thin ;  others  red,  thicU  and  of  a  firm  tex- 
ture ;  some  will  be  thin  and  pale ;  others  red  on  the  inside  and 
pale  on  the  edges ;  some  are  constantly  bathed  with  the  fluids 
of  the  mouth  ;  others  are  dry :  and  these  differences  of  appear- 
ance and  condition  are  as  marked  on  the  tongue  and  gums  as 
they  are  upon  the  lips,  and  are  supposed  to  be  attributable  to 
the  preponderance  or  want  of  existence  in  sufficient  quantity  of 
some  one  or  more  of  the  elementary  principles  of  the  organism. 
Hence,  may  be  said  to  result  the  differences  in  temperament  and 
susceptibility  of  the  body  to  the  action  of  morbid  excitants. 

The  body,  says  Lavater,  is  composed,  after  an  established 
manner,  "of  varying  congruous  and  incongruous  ingredients." 
He  also  believes  "that  there  is,"  to  use  the  metaphor,  "a  par- 
ticular recipe,  or  form  of  mixture,  in  the  great  dispensatory  of 
God,  for  each  individual,  by  which  his  quantity  of  life,  his  kind 
of  sensation,  his  capacity  and  activity  are  determined;  and 
that,  consequently,  each  body  has  its  individual  temperament,  or 
peculiar  degree  of  irritability.  That  the  humid  and  the  dry, 
the  hot  and  the  cold,  "are  the  four  principal  qualities  of  the  cor- 
poreal ingredients,  is  as  undeniable  as  that  earth  and  water,  fire 
and  air,  are  themselves  the  four  principal  ingredients."  Hence, 
he  argues,  "that  there  will  be  four  principal  temperaments;  the 
choleric,  originating  from  the  hot ;  the  phlegmatic,  from  the 
moist ;  the  sanguine,  from  air ;  and  the  melancholic,  from  earth ; 
that  is  to  say,  that  these  predominate  in,  or  are  incorporated 
with,  the  blood,  nerves  and  juices,  and  indeed  in  the  latter,  in 
their  most  subtile,  and  almost  spiritually  active  form.  But  it  is 
equally  indubitable  to  me,  that  these  four  temperaments  are  so 
mtermingled  that  innumerable  others  must  arise,  and  that  it  is 


194  GENERAL   CONSIDERATIONS. 

frequently  difficult  to  discover  which  preponderates;  especially 
since,  from  tlie  combination  and  interchangeable  attraction  of 
those  ingredients,  a  new  power  may  originate,  or  be  put  in  mo- 
tion, the  character  of  which  may  be  entirely  distinct  from  that 
of  the  two  or  three  intermingling  ingredients."  The  truth  of 
these  propositions  will  hardly  be  questioned,  and  their  admission 
at  once  affords  a  satisfactory  explanation  of  the  diiferences  in 
the  susceptibility  of  different  organisms  to  the  attacks  of  disease. 

Admittinir  the  foreoroino;  statement  to  be  correct,  we  think  it 
may  be  safely  assumed,  that  if  the  quality  and  respective  pro- 
portions of  the  materials  furnished  for  the  growth,  reparation 
and  maintenance  of  the  several  organs  of  the  body,  be  good, 
and  in  proper  proportion,  all  the  organs  will  be  well  formed  and 
endowed  with  health,  and,  as  a  consequence,  capable  of  perform- 
ing their  respective  functions  in  a  healthy  manner.  But  if  their 
elementary  ingredients,  to  use  an  expression  of  the  author  from 
whom  we  have  just  quoted,  be  bad,  their  functions  will  be  more 
or  less  feebly  performed. 

These  materials  are  furnished  by  the  blood.*  From  this  fluid, 
each  organ  receives  such  as  are  necessary  to  its  own  particular 
organization.  The  blood,  therefore,  exercises  an  important  in- 
fluence upon  the  whole  system,  determining  the  health  of  all  its 
parts;  which,  as  Delabarre  says,  " is  relative  to  the  quality  of 
the  blood,  and  the  general  health  results  from  that  of  all  parts 
of  the  system."  In  order  to  this,  harmony  must  exist  between 
all  the  organs,  but  in  consequence  of  the  great  variety  and  in- 
termingling of  temperaments  it  rarely  does,  except,  perhaps,  in 
those  in  whom  the  sanguine  predominates,  and  who  have  not  be- 
come enervated  by  irregular  and  luxurious  living.  Even  when 
it  does  exist,  we  are  by  no  means  certain  that  it  will  continue  to 
do  so ;  for,  exposed  as  the  body  is  to  a  thousand  causes  of  dis- 
ease, its  functional  operations  may,  at  almost  any  moment,  be- 
come disturbed.  Among  the  civilized  nations  of  the  earth,  the 
peasantry  of  Great  Britain,  probably,  possess  as  good  consti- 
tutional temperaments  as  are  anywhere  to  be  found ;  and  yet, 
with  these  people,  we  are  told,  that  although  the  sanguineous  pre- 

*  Of  the  various  writers  who  have  treated  upon  this  fluid,  Magendie  ranks  de- 
servedly liigh.  lie  instituted  a  great  variety  of  exiieriments  upon  animals,  which  go 
to  prove,  conclusively,  that  no  one  of  its  constituents  can  be  dispensed  with  without 
manifest  and  serious  injury  to  the  whole  organism. 


GENERAL    CONSIDERATIONS.  195 

dominates  in  a  majority  of  cases,  it  is  combined  and  intermin- 
gled, in  a  greater  or  less  degree,  with  others. 

In  all  of  these  modifications  the  blood  plays  an  important 
part:  it  determines  the  temperament  of  the  individual,  and  by 
consequence,  the  physical  condition  of  all  the  tissues  of  the  body 
subject  to  the  general  laws  of  the  economy.  But  the  dependence 
between  the  solids  and  this  fluid  is  mutual;  it,  also,  is  depend- 
ent upon  them,  and  the  condition  of  the  one  is  relative  to  that 
of  the  other.  The  solids,  if  we  may  be  permitted  the  use  of 
the  metaphor,  are  the  distillery  of  the  fluids,  while  they,  in  turn, 
nourish,  repair,  and  maintain  the  solids.  A  change,  then,  in  the 
condition  of  one,  is  followed  by  a  corresponding  change  in  the 
condition  of  the  other.  If  the  blood  be  of  an  impure  quality,  or 
any  of  the  ingredients  entering  into  its  composition  exist  in  too 
great  or  too  small  quantity,  it  will  fail  to  supply  the  solids  with 
the  materials  necessary  to  the  healthful  performance  of  their 
functions,  and,  if  not  actual  disease,  a  tendency  to  it,  will  be  the 
result.  And,  again,  the  purity  of  the  blood  is  dependent  upon 
the  manner  in  which  the  solids  perform  their  ofiices.  While, 
therefore,  duly  appreciating  the  importance  of  this  fluid,  and  its 
existence  in  a  pure  state,  to  the  general  health  of  the  economy, 
we  cannot  ascribe  to  it,  regardless  of  the  functions  of  the  solids, 
a  controlling  influence  over  the  organism. 

To  distinguish  all  the  nice  and  varied  shadings  of  tempera- 
ment, or  states  of  the  constitutional  health,  by  the  physiogno- 
mical appearances  of  the  body,  is  perhaps  impossible,  or  can 
only  be  done  with  great  difficulty,  and  by  those  who  have  been 
long  exercised  in  their  observance ;  but  to  discover  that  which 
predominates  is  not  so  difficult  a  matter,  and  the  indications  are 
nowhere  more  palpably  manifested  than  in  the  mouth.  By  an 
inspection  of  the  several  parts  of  this  cavity,  together  with  its 
fluids  and  the  earthy  matter  found  upon  the  teeth,  we  believe, 
inductions  may  be  made,  not  only  with  regard  to  the  innate 
constitution,  but  also  with  regard  to  the  present  state  of  health, 
serviceable  both  to  the  dental  and  medical  practitioner;  and,  in 
the  further  prosecution  of  this  inquiry,  we  shall  endeavor  to 
point  out  some  of  the  principal  of  the  indications  here  met 
with,  to  state  the  appearances  by  which  they  are  distinguished, 
and  to  off"er  such  other  general  reflections  as  the  subject  may, 
from  time  to  time,  seem  to  sugsrest. 


CHAPTER    SECOND. 
PHYSICAL  CHARACTERISTICS  OF  THE  TEETH. 

Most  dental  physiologists  have  observed  the  marked  differences 
that  exist  in  the  appearances  of  the  teeth,  gums,  lips,  tongue, 
and  secretions  of  the  mouth  of  different  individuals ;  and  of  that 
earthy  substance,  (commonly  called  tartar,)  deposited  in  a  greater 
or  less  abundance  on  the  teeth  of  every  one;  and  though  all 
may  not  have  sought  their  etiology,  many  have  had  occasion  to 
notice,  at  least,  their  local  indications,  and  to  profit  by  the  in- 
formation which  they  have  thus  obtained.  Nor  have  they  failed 
to  observe  that  the  size,  color,  length  and  arrangement  of  the 
teeth  vary,  and  that  these  are  indicative  of  their  susceptibility 
to  disease. 

There  are  five  principal  classes  or  descriptions  of  teeth,  each 
of  which  differs,  in  some  respects,  from  the  others. 

Class  First. — The  teeth  belonging  to  this  class  are  white,  with 
a  light  cream  colored  tinge  near  tlie  gum,  which  becomes  more 
and  more  apparent  as  the  subject  advances  in  age,  of  a  medium 
size,  rather  short  than  long;  those  of  each  class  of  uniform 
dimensions,  and  very  hard.  This  description  of  teeth  is  most 
frequently  met  with  in  persons  of  sanguineous  temperament,  or, 
at  least,  those  in  whom  this  predominates;  they  rarely  decay,  and 
indicate,  if  not  jnrfect  health,  at  least  a  state  which  bordered 
very  closely  on  it  at  the  time  of  their  dentinification. 

This  first  description  of  teeth  is  occasionally  found  among 
persons  of  all  nations.  They  are  very  common,  especially  in 
the  middle  classes  of  the  inhabitants  of  England,  Ireland  and 
Scotland.  They  are  also  frequently  met  with  in  some  parts  of 
the  United  States,  the  Canadas,  the  mountainous  districts  of 
Mexico,  and  so  far  as  we  have  had  an  opjiovtunity  of  informing 
ourself,  in  France,  Russia,  Prussia  and  Switzerland.  Those  who 
have  them  usually  enjoy  excellent  health,  and  are  seldom  troubled 


CHAEACTERISTICS   OF   THE    TEETH.  197 

■with  dyspepsia  or  any  of  its  concomitants.  It  is  this  kind  of 
teeth  which,  Lavater  says,  he  has  never  met  with,  except  in 
"good,  acute,  candid,  honest  men,"  and  of  whose  possessors  it 
has  been  remarked,  that  their  stomachs  are  always  willing  to 
digest  whatever  their  teeth  are  ready  to  masticate. 

In  confirmation  of  what  has  before  been  said  with  regard  to 
the  influence  w^iich  the  state  of  the  constitutional  health,  at  the 
time  of  the  solidification  of  the  teeth,  exerts  upon  the  suscepti- 
bility of  these  organs  to  morbid  impressions,  it  is  only  necessary 
to  menti(^n  the  fact,  well  known  and  frequently  alluded  to,  of  the 
early  decay  of  a  single  class,  or  a  pair  of  a  single  class  of  teeth, 
in  each  jaw,  while  the  rest,  possessing  the  characteristics  just 
described,  remain  sound  through  life.  Thus  when  it  happens 
that  a  child,  of  excellent  constitution,  is  affected  with  any  severe 
disease ;  the  teeth  which  are  at  the  time  receiving  their  earthy 
salts,  are  found,  on  their  eruption,  to  differ  from  those  which 
have  received  their  solid  material  at  another  time,  when  the 
operations  of  the  body  were  healthfully  performed.  Instead  of 
having  a  white,  smooth  and  uniform  surface,  they  have  a  sort  of 
chalky  aspect,  or  are  faintly  tinged  with  blue,  and  are  rougher 
and  less  uniform  in  their  surfaces.  Teeth  of  this  description 
are  very  susceptible  to  the  action  of  corrosive  agents,  and,  as  a 
consequence,  rarely  last  long. 

But,  not  willing  to  rest  the  correctness  of  these  views  upon 
mere  hypothesis,  we,  in  a  great  number  of  instances,  where  we 
have  seen  teeth  thus  varying  in  their  physical  appearance, 
have  taken  pains  to  inquire  of  those  who  had  an  opportunity  of 
knowing  the  state  of  the  general  health  of  the  individuals,  at  the 
diff'erent  periods  of  dentinification  ;  and  in  every  case  where  we 
have  been  able  to  procure  the  desired  information,  it  has  tended 
to  the  confirmation  of  the  opinion  here  advanced.  Nor  have  we 
neglected  to  improve  the  many  opportunities  that  have  presented, 
in  the  course  of  a  somewhat  extended  professional  career,  of 
making  these  observations. 

Although  the  operations  of  the  economy  are  so  secretly 
carried  on,  that  it  is  impossible  to  comprehend  their  details 
fully,  it  is  known  that  the  phenomena  resulting  therefrom  are 
influenced  and  modified  by  the  manner  in  which  they  are  per- 
formed.   If  they  are  deranged,  the  blood,  from  which  the  earthy 


198  CHARACTERISTICS    OF   THE    TEETH. 

materials  forming  the  basis  of  all  the  osseous  tissues  are  derived, 
is  deteriorated,  and  furnishes  these  salts  in  less  abundance  and 
of  an  inferior  quality.  Hence,  teeth  that  solidify  when  the 
system  is  under  the  influence  of  disease,  do  not  possess  the 
characteristics  necessary  to  enable  them  to  resist  the  assaults  of 
corrosive  agents,  to  which  all  teeth  are  more  or  less  exposed, 
and  which  rarely  affect  those  that  receive  their  solidifying  in- 
gredients from  pure  blood. 

The  calcareous  salts  of  these  organs  are  furnished  chiefly  by 
the  red  part  of  this  fluid,  the  gelatine  is  derived  from  the  white  or 
serous  part; — "whence,"  as  Delabarre  remarks,  "it  results  that 
the  solid it}^  of  these  bones  varies  according  as  one  or  other  of 
these  principles  predominates,"  and  the  relative  proportions  of 
these  are  regulated  by  the  state  of  the  blood  at  the  time  the 
teeth  are  undergoing  solidification. 

The  researches  of  Duhamel  show,  that  bones  acquire  solidity 
no  faster  than  the  parts  which  arc  about  to  ossify  become 
charged  with  red  blood.  The  experiments  of  Haller  are  also 
confirmatory  of  this  opinion.  And  Delabarre,  in  remarking 
upon  the  dentinification  of  the  teeth,  says,  "  the  superficial  layer 
of  the  pulp  reddens  before  it  ossifies,  whilst  all  below  is  entirely 
white ;  soon  another  layer  reddens,  is  ossified,  and  then  whitens, 
and  so  on,  successively." 

The  increase  of  density  which  the  teeth  continue  through 
life  very  gradually  to  acquire,  may  seem  to  militate  somewhat 
against  this  theory,  as  the  fluid  conveyed  to  the  dentine  subse- 
quent to  solidification  is  not  even  so  much  as  tinged  with  red ; 
but  it  is  a  probability  amounting  to  certainty,  that  the  fluid  de- 
rived from  the  pulp  and  circulating  in  the  dentinal  tubuli,  is 
abundantly  sufficient  to  maintain  the  integrity  of  the  dentine,  or 
even  to  contribute  to  the  condensation  of  that  substance. 

Class  Second. — Having  digressed  thus  far,  we  shall  now  pro- 
ceed to  notice  the  teeth  belonging  to  the  second  class.  They 
have  a  faint,  azure  blue  appearance:  are  rather  long  than  short; 
the  incisors  are  generally  thin  and  narrow;  the  cuspids  are 
usually  round  and  pointed;  the  bicuspids  and  molars  small  in 
circumference,  with  prominent  cusps  and  protuberances  upon 
their  grinding  surfaces.  In  some  cases  the  lateral  incisors  are 
very  small  and  pointed. 


CHARACTEKISTICS    OF    THE    TEETH.  199 

Teeth  possessing  these  characteristics  are  usually  very  sen- 
sitive, more  easily  acted  upon  than  teeth  of  the  first  class  hy 
corrosive  agents,  and  to  the  ravages  of  which,  unless  great  atten- 
tion is  paid  to  their  cleanliness,  they  often  fall  early  victims. 
They  are  more  frequently  affected  with  atrophy,  or  have  upon 
their  surfaces  white,  brown  or  opaque  spots,  varjnng  in  size  and 
number;  several  are  sometimes  found  upon  a  single  tooth,  and 
in  some  instances  every  tooth  in  the  mouth  is  more  or  less 
marked  with  them. 

But  this  is  not  the  only  description  of  teeth  liable  to  be 
affected  with  this  disease.  These  spots  are  occasionally  met 
with  on  teeth  of  every  degree  of  density,  shape,  shade  and  size, 
but  they  are,  probably,  more  frequently  seen  on  teeth  of  the 
second  class  than  on  those  first  described;  besides  which  it  often 
happens  that  they  are  affected  with  erosion  on  emerging  from 
the  gums,  and  sometimes  so  badly  as  to  place  either  their  resto- 
ration and  preservation  beyond  the  reach  of  art.  This  species 
of  erosion,  or  that  which  occurs  previously  to  the  eruption  of  the 
teeth,  is  caused  by  some  diseased  condition  of  the  fluid  which 
surrounds  them  before  they  appear  above  the  gums,  and  is  de- 
nominated congenital. 

Teeth  like  those  now  under  consideration,  are  indicative  of  a 
weakly  constitution,  of  a  temperament  considerably  removed 
from  the  sanguineous,  and  of  blood  altogether  too  serous  to 
furnish  materials  such  as  are  necessary  for  building  up  a  strong 
and  healthy  organism.  They  are  more  common  to  females  than 
males,  though  many  of  the  latter  have  them.  They  are  met 
with  among  people  of  all  countries,  but  more  frequently  among 
those  who  reside  in  sickly  localities,  and  with  individuals  whose 
systems  have  become  enervated  by  luxurious  living.  In  Great 
Britain  they  are  more  rare  than  in  the  United  States,  and  those 
who  have  them  seldom  attain  to  a  great  age.  Nevertheless, 
some,  under  the  influence  of  a  judicious  regimen,  and  a  salu- 
brious climate,  though  innately  delicate,  do  acquire  a  good  con- 
stitution, and  live  to  a  great  age  ;  while  the  teeth,  less  fortunate, 
unless  the  most  rigid  and  constant  attention  is  paid  to  the  use 
of  the  means  necessary  for  their  preservation,  generally  fall 
early  victims  to  the  ravages  of  disease. 

Class  Third. — The  teeth    of  this  class,  though  differing  in 


200  CHARACTERISTICS    OF   THE    TEETH. 

many  of  tlieir  characteristics  from  those  last  described,  are, 
nevertheless,  not  unlike  them  in  texture  and  sensibility  to 
disease.  They  are  larger  than  teeth  of  the  first  or  second  class; 
their  faces  are  rough  and  irregular,  with  protuberances  arising, 
not  only  from  the  grinding  surfaces  of  the  bicuspids  and  molars, 
but  also,  not  unfrequently,  from  their  sides,  with  correspond- 
ingly deep  indentations.  They  have  a  muddy  white  color.  The 
crowns  of  tlie  incisors  of  both  jaws  are  broad,  long  and  thick. 
The  posterior  or  palatine  surfaces  of  those  of  the  superior 
maxilla  are  rough,  and  usually  deeply  indented.  In  the  ma- 
jority of  cases  tlieir  arrangement  is  quite  regular,  though  fre- 
quently found  to  project.  The  alveolar  ridge  usually  describes 
a  broad  arch.  The  excess  in  size,  both  here  and  in  the  teeth, 
seems  to  consist  more  of  gelatine  than  calcareous  phosphate. 
This  description  of  teeth  decay  readily,  and  in  some  instances 
appear  to  set  at  defiance  the  resources  of  the  dentist.  They  are 
liable  to  be  attacked  at  almost  every  point,  but  more  particu- 
larly in  their  indentations  and  approximal  surfaces. 

The  author  is  acquainted  with  a  family,  consisting  of  seven  or 
eight  members,  most  of  whom  are  adults,  all  having  this  sort  of 
teeth.  The  most  thorough  attention  has  been  paid  by  each,  and 
yet  all  have  lost  most  of  their  teeth.  They  are  usually  first 
attacked  in  their  approximal  surfaces  and  indentations,  but 
neither  their  labial  faces  nor  most  prominent  points  are  exempt 
from  caries.  No  sooner  is  its  progress  arrested  in  one  place  or 
part  than  it  appears  in  another.  The  author  has  had  occasion 
to  fill  a  single  tooth  in  as  many  as  four,  five,  and  even  six 
difl"erent  places;  and  in  this  way,  though  his  efi"orts  at  the  pre- 
servation of  any  considerable  number  have  proved  unavailing,  he 
has  been  able  to  save  some  of  them.  But  it  is  not  necessary  to 
particularize  cases.  Every  dentist  has  seen  teeth  of  this  de- 
scription. 

The  corrosive  properties  of  the  fluids  of  the  mouth,  however, 
are  sometimes  so  changed  by  an  amelioration  of  the  constitution, 
that  notwithstanding  the  great  susceptibility  of  the  teeth  to 
disease,  they  are  sometimes  preserved  to  a  late  period  of  life,  or 
until  the  general  health  relapses  into  its  former,  or  some  other 
unfavorable  condition.  This  has  happened  in  several  instances 
that  have  come  under  the  author's  immediate  observation,  and 


CHARACTERISTICS    OF   THE    TEETH.  201 

it  should  be  borne  in  mind  that  the  solvent  qualities   of  these 
juices  are  influenced  by  the  state  of  the  constitutional  health. 

Class  Fourth. — Teeth  of  this  class  usually  have  a  white 
chalky  appearance,  are  unequally  developed,  and  of  a  very  soft 
texture.  They  are  easily  acted  upon  by  corrosive  agents,  and 
like  the  teeth  last  noticed,  generally  fall  speedy  victims  to 
disease,  unless  great  care  is  taken  to  secure  their  preservation. 

Persons  who  have  teeth  such  as  described  in  classes  three  and 
four,  generally  have  what  Laforgue  calls  lymphatico-serous  tem- 
peraments. Their  blood  is  usually  pale,  the  fluids  of  the  mouth 
abundant,  and  for  the  most  part  exceedingly  viscid.  They  do 
not  have  that  white  frothy  appearance  observable  in  healthy, 
sanguineous  individuals. 

As  teeth  that  are  neither  too  large  nor  too  small,  and  that 
have  a  close,  compact  texture,  and  tinged  with  yellow,  are  in- 
dicative of  an  originally  good  constitution,  whatever  it  may  be 
at  the  present  time ;  so  those  which  are  long,  narrow,  and  faintly 
tinged  with  blue,  as  well  as  those  that  greatly  exceed  the  ordi- 
nary size,  and  that  are  irregular  in  shape,  and  have  a  rough, 
muddy  appearance,  furnish  assurance  of  a  constitution  originally 
bad.  The  first  of  the  latter  descriptions  of  teeth  are  more  fre- 
quently met  with  among  females  than  males,  and  among  those 
of  strumous  habit,  than  those  in  whom  this  diathesis  does  not 
exist. 


Class  Fifth. — The  teeth  belonging  to  this  class  are  character- 
ized by  whiteness  and  a  pearly  gloss  of  the  enamel.  They  are 
long,  and  usually  small  in  circumference,  though  sometimes  well 
developed.  They  are  regarded  by  many  as  denoting  a  tendency 
to  phthisis  pulmonalis,  and  are  supposed  by  some  to  be  very 
durable ;  but  the  author  has  observed  that  individuals  who  have 
this  sort  of  teeth,  when  attacked  by  febrile  or  any  other  form  of 
disease  having  a  tendency  to  alter  the  fluids  of  the  body,  are 
very  subject  to  tooth-ache  and  caries ;  and  that  when  this  con- 
dition of  the  general  system  is  continued  for  a  considerable 
length  of  time,  the  teeth,  one  after  another,  in  rapid  succession, 
crumble  to  pieces. 

It  would  seem  from  this  circumstance,  that  the  fluids  of  the 
14 


202  CHARACTERISTICS   OF   THE   TEETH. 

mouth  in  subjects  of  strumous  habit,  if  free  from  other  morbid 
tendencies,  are  less  prejudicial  to  the  teeth  than  they  are  in 
most  other  constitutions,  and  the  author  is  of  the  opinion  that 
it  is  owing  to  this  that  they  are  so  seldom  attacked  by  caries. 

M.  Delabarre  believes,  that  caries  supervenes  upon  this  dis- 
ease, and  is  a  consequence  of  the  general  debility  engendered  by 
it.  Now,  this  is  directly  opposed  to  all  observation  on  the  sub- 
ject, for  it  is  Avell  known  that  teeth  are  less  affected  by  this 
disease  than  almost  any  other,  and  it  is  unfortunate  for  the 
doctrine,  which  he  in  another  place  advocates — that  the  solid 
tissue  of  these  organs  is  softened  by  the  arteries  ceasing  to 
supply  it  with  calcareous  materials — that  he  should  have  resorted 
to  this  argument.  Its  absurdity  is  rendered  apparent  by  his 
own  showing,  and  that,  too,  in  the  paragraph  succeeding  the 
one  in  which  the  argument  is  used.  He  says,  "  Whatever  may 
be  the  diseased  condition  of  the  teeth,  they  may  be  examined  as 
unexceptionable  evidence,  that  will  inform  us  whether  the  patient 
owes  his  present  state  of  health  to  a  predisposition,  or  whether, 
having  supervened  during  the  course  of  his  life,  it  depends  on 
an  accidental  cause." 

If  the  state  of  the  health,  subsequent  to  dentinification  were 
capable  of  diminishing  or  increasing  the  density  of  these  organs, 
we  could  learn  nothing  by  inspection  of  the  primordial  consti- 
tution. Nor  would  we,  therefore,  be  able  to  determine  whether 
the  present  state  of  health  were  the  result  of  constitutional  pre- 
disposition, or  of  some  other  cause ;  for,  if  the  teeth  were  sub- 
ject to  changes,  like  other  parts  of  the  body,  their  physical 
condition  might  be  different  to-day  from  what  it  was  yesterday, 
and  a  diagnosis,  founded  upon  their  appearance,  would  be 
nothing  more  than  mere  vague  conjecture. 

But,  although  Delabarre  is  in  many  things  somewhat  incon- 
sistent, a  number  of  his  views  are  correct ;  and  fcAv  men  have 
contributed  more  largely,  by  observation  and  experience,  to  the 
advancement  of  the  science  of  the  teeth  than  he  has  done. 

In  speaking  of  persons  who  have  teeth,  which,  though  beauti- 
ful from  having  smooth  and  apparently  polished  surfaces,  pre- 
sent shades  intermixed  with  a  dirty  white,  he  says,  they  "  havo 
had  alternations  of  good  and  indifferent  health  during  the 
formation   of  the  enamel.     These  teeth,"  he  continues,  "ordi- 


CHARACTERISTICS    OF   THE    TEETH.  203 

narily  have  elongated  crowns,  and  many  present  marks  of  con- 
genital atrophy."  Again,  he  observes,  "Teeth  of  this  sort 
deceive  us  by  appearing  more  solid  than  they  are  ;  they  remain 
sound  until  about  the  age  of  fourteen  or  eighteen  ;  at  this  period 
a  certain  number  of  them  decay,  especially  when  in  infancy  the 
subject  was  lymphatic,  and  continued  to  be  so  in  adolescence. 
This  description  of  teeth  is  frequently  met  with  among  the  richer 
classes,  in  which  children  born  feeble,  reach  puberty  only  by 
means  of  great  care,  and,  consequently,  owe  .their  existence 
solely  to  the  unremitting  attention  of  their  parents,  and  the 
strengthening  regimen  that  the  physician  has  caused  them  con- 
stantly to  pursue.  Having  reached  the  eighteenth  or  twentieth 
year,  their  health  is  confirmed,  but  the  mucous  membranes  ever 
after  have  a  tendency  to  be  aflFected ;  the  redder  color  of  the 
mouth,  more  especially  its  interior  part,  and  that  of  the  lips, 
and  the  upper  part  of  the  palate,  which,  by  degrees,  discovers 
itself  as  the  subject  gradually  advances  in  years,  showing  an 
ameliorated  condition.  It  is  thus  that  numerous  persons,  having 
gained  a  sanguineous  temperament,  would  deceive  us  ;  if  it  were 
not  that  some  marks  of  erosion  are  seen  on  the  masticating  sur- 
faces of  the  first  permanent  molars,  which  informs  us  that  the 
present  health  is  the  result  of  amelioration." 

There  are  other  cases  in  which  the  teeth  are  of  so  inferior  a 
quality,  that  they  no  sooner  emerge  from  the  gums  than  they 
are  attacked  and  destroyed  by  caries ;  while  the  subjects  who 
possess  them,  are  enabled,  by  skillful  treatment,  to  overcome 
the  morbid  constitutional  tendencies,  against  which,  during  the 
earlier  years  of  their  existence,  they  had  to  contend,  and  event- 
ually, to  acquire  excellent  health.  But  in  forming  a  prognosis, 
it  is  essential  to  ascertain  whether  the  general  organic  derange- 
ment which  prevented  the  teeth  from  being  well  formed,  and 
thus  gave  rise  to  their  premature  decay,  is  hereditary,  or  whether 
it  has  been  produced  by  some  accidental  cause  subsequent  to 
birth.  The  procurement  of  health  in  the  former  case  will  be 
less  certain  than  in  the  latter,  for  when  the  original  elements  of 
the  organism  are  bad,  the  attainment  of  a  good  constitution  is 
more  difficult. 

Persons  of  sanguineo-mucous  temperaments,  having  sufiered  in 
early  childhood   from    febrile  or  inflammatory  diseases,  often 


204  CHARACTERISTICS   OF   THE   TEETH. 

have  their  teeth  affected  with  what  Duval  calls  the  decorticating 
process  (denudation  of  their  enamel),  resulting,  no  doubt,  from 
the  destruction  of  the  bond  of  union  between  it  and  the  dentine. 
There  are  other  characteristics  which  the  teeth  present  in 
shape,  size,  density,  and  color,  and  from  which  valuable  induc- 
tions might  be  made,  both  with  regard  to  the  innate  constitution 
and  the  means  necessary  to  their  own  preservation ;  but  as  the 
limits  assigned  to  this  part  of  our  subject  will  not  admit  of 
their  consideration,  we  shall  conclude  by  observing,  that  the 
appearances  of  these  organs  vary  almost  to  infinity.  Each  is 
indicative  of  the  state  of  the  general  health  at  the  time  of  their 
formation,  and  of  their  own  physical  condition  and  susceptibility 
to  disease. 


II 


CHAPTER    THIRD. 

PHYSICAL  CHARACTERISTICS  OF  THE  GUMS. 

Little  can  be  ascertained  concerning  the  intimate  constitu- 
tion from  an  inspection  of  the  gums.  Subject  to  the  laws  of  the 
general  economy,  their  appearance  varies  with  the  state  of  the 
general  health  and  the  condition  and  arrangement  of  the  teeth. 
Although  the  proximate  cause  of  disease  in  them  may  be 
specified  as  local  irritation — produced  by  depositions  of  tartar 
upon  the  teeth,  or  decayed,  dead,  loose  or  irregularly  arranged 
teeth,  or  by  a  vitiated  state  of  the  fluids  of  the  mouth,  resulting 
from  general  organic  derangement,  or  any  or  all  of  the  first 
mentioned  causes — their  susceptibility  to  morbid  impressions  is 
influenced  to  a  considerable  extent  by  the  constitutional  health ; 
and  the  state  of  this  determines,  too,  the  character  of  the  mor- 
bid efi'ects  produced  upon  them  by  local  irritants.  For  example, 
the  deposition  of  a  small  quantity  of  tartar  upon  the  teeth,  or  a 
dead  or  loose  tooth,  would  not,  in  a  healthy  person,  of  a  good 
constitution,  give  rise  to  anything  more  than  slight  increased 
vascular  action  in  the  margin  of  the  gums  in  contact  with  it; 
while  in  a  scorbutic  subject,  it  would  cause  them  to  assume  a 
dark  purple  appearance  for  a  considerable  distance  around,  to  be- 
come swollen  and  flabby,  to  separate  and  retire  from  the  necks 
of  the  teeth,  or  to  grow  down  upon  their  crowns,  to  ulcerate  and 
bleed  from  the  slightest  injury,  and  to  exhale  a  fetid  odor.  In 
proportion  as  this  disposition  of  body  exists,  their  liability  to  be 
thus  afi'ected  is  increased ;  and  it  is  only  among  constitutions  of 
this  kind  that  that  peculiar  preternatural  morbid  growth  takes 
place,  by  which  the  whole  of  the  crowns  of  the  teeth  sometimes 
become  almost  entirely  imbedded  in  tlieir  substance. 

But,  notwithstanding  the  dependence  of  the  condition  of  the 
gums  upon  the  state  of  the  constitutional  health,  they  are  occa- 
sionally aflfected  with  sponginess  and  inflammation  in  the  best 
temperaments,  and  in  individuals  of  uninterrupted  good  health. 


206  CHARACTERISTICS    OF   THE   GUMS. 

Tlic  wrong  position  of  a  tooth,  by  causing  continued  tension  of 
the  gums  investing  its  alveolus,  sooner  or  later  gives  rise  to 
chronic  inflammation  in  them  and  the  alveolo-dental  periosteum, 
and  gradual  wasting  of  their  substance  about  the  mal-placed 
organ.  The  causes  of  tooth-ache,  too,  often  produce  the  same 
efiects;  the  accumulation  of  salivary  calculus  upon  teeth,  how- 
ever small  the  quantity,  is  likewise  prejudicial. 

All  of  these  may  occur  independently  of  the  state  of  the  gen- 
eral health.  A  bad  arrangement  of  the  best  constituted  teeth, 
and  tooth-ache  may  be  produced  by  a  multitude  of  accidental 
causes,  disconnected  with  the  functional  operations  of  other  parts 
of  the  body. 

While,  therefore,  the  appearance  and  physical  condition  of  this 
peculiar  and  highly  vascular  structure  are  influenced  in  a  great 
degree  by  habit  of  body,  they  are  not  diagnostics  that  always, 
and  with  unerring  certainty,  indicate  the  pathological  state  of 
the  general  system.  It  can,  however,  in  by  far  the  larger  num- 
ber of  cases,  where  the  gums  are  in  an  unhealthy  condition,  be 
readily  ascertained  whether  the  disease  is  altogether  the  result 
of  local  irritation,  or  whether  it  is  favored  by  constitutional  ten- 
dencies. 

In  childhood,  or  during  adolescence,  when  the  formative  forces 
of  the  body  are  all  in  active  operation,  and  the  nervous  suscepti- 
bilities of  every  part  of  the  organism  highly  acute,  the  sympa- 
thy between  the  gums  and  other  parts  of  the  system,  and  par- 
ticularly the  stomach,  is,  perhaps,  greater  than  at  any  other 
period  of  life.  The  general  health,  too,  at  this  time  is  more 
fluctuating,  and  with  all  the  changes  this  undergoes,  the  appear- 
ances of  the  gums  vary.  Moreover,  there  are  operations  carried 
on  beneath  and  within  their  substance,  which  are  almost  con- 
stantly altering  their  appearance  and  physical  condition  ;  and 
which,  being  additional)}'  influenced  by  various  states  of  health 
and  habits  of  body,  it  may  readily  be  conceived  that  those  met 
with  in  one  case,  might  be  looked  for  in  vain  in  another. 

Having  arrived  at  that  age  when  all  the  organs  of  the  body 
are  in  full  vigor  of  maturity,  and  not  under  the  debilitating  in- 
fluences to  which  they  are  subject  during  the  earlier  periods  of 
life,  the  gums  participate  in  the  happy  change,  and  as  a  conse- 
quence, present  less  variety  in  their  characteristics.     The  gene- 


CHARACTERISTICS   OF   THE   GUMS.  207 

ral  irritability  of  the  system  is  not  now  so  great,  the  gums  are 
less  susceptible  to  the  action  of  irritating  agents,  and  as  a  con- 
sequence, less  frequently  affected  with  disease ;  but  as  age  ad- 
vances, and  the  vital  energies  begin  to  diminish,  the  latent  ten- 
dencies of  the  body  are  re-awakened,  and  they  are  again  easily 
excited  to  morbid  action. 

In  the  most  perfect  constitutions,  and  during  adolescence,  they 
present  the  following  appearances :  they  have  a  pale  rose-red 
color,  a  firm  consistence,  a  slightly  uneven  surface ;  their  mar- 
gins form  along  the  outer  surfaces  of  the  dental  circle  beautiful 
and  regular  festoons,  and  the  mucous  membrane,  here,  as  well 
as  in  other  parts  of  the  mouth,  has  a  fresh,  lively,  roseate  hue. 

The  time  for  the  moulting  of  a  primary  tooth  is  announced 
some  weeks  before  it  takes  place,  by  increased  redness  and  slight 
tumefaction  of  the  edges  and  apices  of  the  gums  surrounding  it. 
The  eruption  of  a  tooth,  whether  of  the  first  or  second  set,  is 
also  preceded  by  similar  phenomena  in  the  gums  through  which 
it  is  forcing  its  way,  and  these  will  be  more  marked  as  the  con- 
dition of  the  system  is  unhealthy,  or  as  the  habit  of  body  is 
bad. 

If  the  health  of  the  subject  continues  good,  and  the  teeth  are 
well  arranged,  and  the  necessary  attention  to  their  cleanliness 
be  strictly  observed,  the  characteristics  just  enumerated  will  be 
preserved  through  life,  except  there  will  be  a  slight  diminution 
of  color  in  them,  after  the  age  of  puberty  until  that  of  the  cli- 
macteric period  of  life,  when  they  will  again  assume  a  somewhat 
redder  appearance.  But  if  the  health  of  the  subject  becomes 
impaired,  or  the  teeth  be  not  regularly  arranged,  or  wear  off,  or 
are  not  kept  free  from  all  lodgment  of  extraneous  matter,  their 
edges,  and  particularly  their  apices,  will  inflame,  swell,  and  be- 
come more  than  ordinarily  sensitive. 

The  gradual  wasting  or  destruction  of  the  margins  of  the 
gums  around  the  necks  of  the  teeth,  which  sometimes  takes 
place  in  the  best  constitutions,  and  is  supposed  by  some  to  be 
the  result  of  general  atrophy,  is  ascribable,  we  have  no  doubt,  to 
some  one  or  other  of  these  causes ;  favored,  perhaps,  by  a  dimi- 
nution of  vitality  in  the  teeth,  whereby  they  are  rendered  more 
obnoxious  to  the  more  sensitive  and  vascular  parts  within  which 
their  roots  are  situated.     That  these  are  the  causes  of  the  affec- 


208  CHARACTERISTICS    OF   THE    GUMS. 

tion,  (for  it  is  evidently  the  result  of  diseased  action  in  the 
gums,)  is  rendered  more  than  probable,  by  the  fact,  that  it  rarely 
occurs  with  those  who,  from  early  childhood,  have  been  in  the 
regular  and  constant  habit  of  thoroughly  cleansing  their  teeth 
from  four  to  five  times  a  day. 

Mr.  Bell,  however,  while  he  thinks  it  may  occasionally  be  an 
"indication  of  a  sort  of  premature  old  age,"  does  not  believe  it 
can  "  always  be  thus  accounted  for,  as  it  is  sometimes  seen  in 
young  persons,"  and  "doubtless  arises,"  he  says,  "from  the 
same  causes  as  those  presently  to  be  considered,"  (alluding  to 
what  he  afterwards  says  upon  the  same  subject,)  "as  occasioning 
a  similar  loss  of  substance  in  these  parts,  when  attended  with 
more  or  less  of  diseased  action."  We  cannot,  for  reasons  al- 
ready assigned,  concur  with  him  in  the  opinion  that  it  "  occasion- 
ally takes  place  without  any  obvious  local  or  constitutional  morbid 
action." 

Although  possessed  of  a  good  constitution,  a  person  may,  by 
intemperance,  debauchery,  or  long  privation  of  the  necessary 
comforts  of  life,  or  by  protracted  febrile  or  other  severe  kinds  of 
disease,  have  his  assimilative  and  all  the  other  organs  of  the 
body  so  enervated,  as  to  render  every  part  of  the  system  highly 
susceptible  to  morbid  impressions  of  every  sort ;  but  still,  this 
general  functional  derangement  rarely  predisposes  the  structure 
now  under  consideration,  to  any  of  the  more  malignant  forms  of 
disease  occasionally  known  to  attack  it  in  subjects  possessed  of 
less  favorable  constitutions.  The  margins  of  the  gums  may  in- 
flame, become  turgid,  ulcerate,  and  recede  from  the  necks  of  the 
teeth,  and  the  whole  of  their  substance  be  involved  in  an  un- 
healthy condition;  but  they  will  seldom  be  attacked  with  scirrhous 
or  fungous  tumors,  or  bad  conditioned  ulcers,  or  affected  with 
preternatural  morbid  growths  ;  and  in  the  treatment  of  their  dis- 
eases, we  can  always  form  a  more  favorable  prognosis  in  persons 
of  this  description,  than  those  coming  into  the  world  with  some 
specific  morbid  tendency. 

But  the  occurrence  of  severe  constitutional  disease,  even  in 
these  subjects,  is  followed  by  increased  irritability  of  the  gums ; 
so  that  the  slightest  cause  of  local  irritation  gives  rise  to  an  afflux 
of  blood  to,  and  stasis  of  this  fluid  in,  their  capillaries. 

The  teeth  of  persons  thus  happily  constituted,  are  endowed 


CHARACTEKISTICS    OF   THE   GUMS.  209 

with  characteristics,  such  as  have  been  represented  as  belonging 
to  those  of  the  best  quality.  Thej  are  of  a  medium  size,  both 
in  length  and  volume,  white,  compact  in  their  structure,  gene- 
rally well  arranged,  and  seldom  affected  with  caries. 

Another  constitution  is  observed,  in  which  the  gums,  though 
partaking  somewhat  of  the  characteristics  just  described,  differ 
from  them  in  some  particulars.  Their  color  is  of  a  deeper  ver- 
milion ;  their  edges  rather  thicker,  their  structure  less  firm,  and 
their  surface  not  so  rough,  but  more  humid.  The  mucous  mem- 
brane has  a  more  lively  and  animated  appearance.  They  are 
more  sensitive  and  more  susceptible  to  the  action  of  local  irri- 
tants, with  morbid  tendencies  more  increased  by  general  organic 
derangement,  than  when  possessed  of  the  appearances  first  men- 
tioned. 

When  in  a  morbid  condition,  the  disease,  though  easily  cured 
by  proper  treatment,  is,  nevertheless,  more  obstinate,  and  when 
favored  by  constitutional  derangement,  assumes  a  still  more  ag- 
gravated form.  Their  predisposition  to  disease  is  so  much  in- 
creased by  long  continued  disturbance  of  the  general  system, 
and  especially  during  youth,  and  by  febrile  or  inflammatory  afiec- 
tions,  that  not  only  their  margins,  but  their  whole  substance, 
sometimes  become  involved  in  inflammation  and  sponginess,  fol- 
lowed by  ulceration  of  their  edges,  and  recession  from  the  necks 
of  the  teeth,  which,  in  consequence,  loosen,  and  often  drop  out. 
But  gums  of  this  kind,  like  those  first  described,  seldom  grow 
down  upon  the  crowns  of  the  teeth.  Neither  are  they  very  liable 
to  be  attacked  with  scirrhous  or  fungous  tumors,  or  any  form  of 
disease  resulting  in  sanious  or  other  malignant-conditioned  ulcers. 
Indeed,  with  diseases  of  this  kind,  they  are  not,  perhaps,  ever 
affected,  except  in  those  cases  where  every  part  of  the  body  has 
become  exceedingly  depraved  by  intemperance,  debauchery,  or 
some  other  cause. 

The  teeth  of  those  whose  gums  are  of  this  description,  if  well 
arranged  and  kept  constantly  clean,  and,  if  the  secretions  of  the 
mouth  be  not  vitiated  by  general  disease,  will,  in  most  cases,  re- 
main healthy  through  life. 

It  is  only  among  sanguineous  persons  that  this  description  of 
gums  is  met  with,  and  the  teeth  of  subjects  of  this  kind  are  gen- 
erally of  excellent  quality,  and  though  more  liable  to  be  attacked 


210  CHARACTERISTICS    OF   THE   GUMS. 

by  caries  than  those  first  noticed,  they  are  sehlom  affected  with 
it. 

In  sanguineo-serous  and  strumous  subjects,  the  gums  are  pale, 
and  though  their  margins  are  thin  and  well  festooned,  often  ex- 
ude, after  the  twenty-fifth  or  thirtieth  year,  a  small  quantity  of 
muco-purulent  matter,  which,  on  pressure,  oozes  from  between 
them  and  the  necks  of  the  teeth.  Their  texture  is  usually  firm, 
and  they  are  not  very  liable  to  become  turgid.  They  often  re- 
main in  this  condition  to  a  late  period  of  life,  without  undergoing 
any  very  perceptible  change.  Their  connection  with  the  necks 
of  the  teeth  and  alveolar  processes  appears  weak,  but  they  rarely 
separate  from  them. 

In  remarking  upon  individuals  having  such  constitutions,  M. 
Delabarre  says,  that  if  they  "  abuse  their  physical  powers,"  by 
an  injudicious  regimen,  or  too  much  study,  they  become  ener- 
vated and  "  are  subject  to  chronic  sanguineous  obstructions  of  the 
capillaries  of  the  lungs,  and  to  profuse  hemorrhages."  Dyspep- 
sia, chronic  hepatitis,  and  diseases  in  which  the  primce  vice  gener- 
ally are  more  or  less  involved,  are  not  unfrequent,  and  are  in- 
dicated by  increased  irritability,  and  sometimes,  a  pale  yellow- 
ish appearance  of  the  gums.  In  jaundice,  the  yellow  serosity  of 
the  blood  is  very  apparent  in  the  capillaries  of  this  structure. 

These  constitutions  are  more  common  in  females  than  males, 
in  the  rich  than  the  poor,  and  in  pei'sons  of  sedentary  habits 
than  in  those  who  use  invigorating  exercise.  If  at  any  time  dur- 
ing life  the  health  is  ameliorated,  the  gums  assume  a  fresher  and 
redder  appearance,  and  the  exudation  of  muco-purulent  matter 
from  between  them  and  the  necks  of  the  teeth  ceases. 

In  mucous  dispositions,  the  gums  have  a  smooth,  shining  ap- 
pearance, and  are  rather  more  highly  colored  than  the  preced- 
ing. Their  margins,  also,  are  thicker,  more  flabby,  and  not  so 
deeply  festooned ;  they  are  more  irritable,  and,  consequently, 
more  susceptible  to  morbid  impressions. 

If,  with  this  disposition,  there  be  combined  a  scorbutic  or  scro- 
fulous tendency,  the  gums  during  early  childhood,  in  subjects 
which,  from  scanty  and  unwholesome  diet,  have  become  greatly 
debilitated,  are  liable,  besides  the  ordinary  forms  of  disease,  to 
another — characterized  by  their  separation  from,  and  exfoliation 


CHARACTERISTICS    OF   THE   GUMS.  211 

of,  the  alveolar  processes,  accompanied  by  a  constant  discharge 
of  sanies.  This  form  of  disease,  however,  though  peculiar  to 
childhood,  and  wholly  confined  to  the  indigent,  is  by  no  means 
common. 

These  constitutions  are  rarely  met  with,  except  amoug  persons 
who  live  in  cellars,  and  damp  and  closely  confined  rooms  in  large 
cities,  and  in  low,  damp,  and  sickly  districts  of  country.  The 
mucous  membrane  in  subjects  of  this  kind  is  exceedingly  irri- 
table, and  secretes  a  large  quantity  of  mucus. 

In  alluding  to  this  species  of  disposition,  M.  Delabarre  says, 
"  in  children,  the  skin  is  ordinarily  white  and  tender ;  neverthe- 
less, it  is  sometimes  brown  and  wrinkled.  They  are  usually  fra- 
gile and  weak  ;  their  blood  is  pale,  their  nutrition  is  imperfectly 
effected.  In  females,  about  the  age  of  puberty,  the  vertebral 
column  is  disposed  to  curve,  because,"  says  he,  "at  this  period, 
the  vital  energies  are  principally  directed  toward  the  uterus,  and, 
in  consequence,  although  so  very  necessary  in  the  osseous  sys- 
tem, they  appear  to  be  weak. 

"  The  number  of  observations  that  I  have  collected  during  my 
practice  in  the  city,  and  in  several  public  institutions,  have  con- 
firmed me  in  the  opinion,  that  it  is  in  this  constitution,  especially, " 
(alluding  to  the  mucous,)  "  that  the  children  of  whom  we  have  just 
spoken,  are  met  with.  The  organic  life  in  them  has  so  little 
energy,  that  a  local  cause  on  a  certain  point,  operates  with  greater 
activity  than  it  would  otherwise  do,  sensibly  diminishing  the  as- 
similative force  at  almost  all  other  points.  It  is  also  probable,  that 
the  development  of  ganglionic  obstructions  during  dentition,  are, 
many  times,  owing  to  the  diminution  of  the  sensibility  in  the 
lymphatics." 

"  We  may  also  remark,"  says  he,  "  that,  their  skin  being  very 
susceptible,  the  sympathy  established  between  it  and  the  mucous 
membrane,  renders  individuals  of  this  kind  very  liable  to  con- 
tract rheums,  and  gastric  and  intestinal  afiections ;  they  are, 
likewise,  subject  to  easy  night  sweats,  and  vomitings  of  a  sero- 
mucous  fluid,"  etc. 

Persons  even  thus  unhappily  constituted,  do,  sometimes,  by 
change  of  residence  and  judicious  regimen,  acquire  tolerably 
good  constitutions.  Little  advantage,  however,  is  derived  from 
these,  unless  they  are  had  recourse  to  before  the  twenty-fifth  or 


212  CHARACTERISTICS   OF   THE  GUMS. 

thirtieth  year  of  age,  though  they  may  prove  beneficial  at  a  much 
later  period. 

The  gums,  in  scorbutic  persons,  have  a  reddish  brown  color ; 
their  margins  are  imperfectly  festooned,  and  thick ;  their  struc- 
ture rather  disposed  to  become  turgid,  and  ever  ready,  on  the 
presence  of  the  slightest  cause  of  local  irritation,  to  take  on  a 
morbid  action.  When  thus  excited,  the  blood  accumulates  in 
their  vessels,  where,  from  its  highly  carbonized  state,  it  gives  to 
the  gums  a  dark,  purple,  or  brown  appearance  ;  they  SAvell,  and 
become  spongy  and  flabby,  and  bleed  from  the  slightest  touch. 
To  these  symptoms,  supervene — the  exhalation  of  a  fetid  odor,  the 
destruction  of  the  bond  of  union  between  them  and  the  necks  of 
the  teeth,  suppuration  and  recession  of  their  margins  from  the 
same,  gradual  wasting  of  the  alveolar  cavities,  loosening,  and 
not  unfrequently,  the  loss  of  several,  or  the  whole  of  the  teeth. 
These  are  the  most  common  results,  but,  sometimes,  they  take 
on  other  and  more  aggravated  forms  of  diseased  action.  Pre- 
ternatural prurient  growths  of  their  substance,  fungous  and 
scirrhous  tumors,  ichorous  and  other  malignant,  ill-conditioned 
ulcers,  etc. 

The  occurrence  of  alveolar  abscess  in  dispositions  of  this  kind 
is  often  followed  by  necrosis  and  exfoliation  of  portions  of  the 
maxillary  bone,  and  the  effects  which  result  to  the  gums  are 
always  more  pernicious  than  in  habits  less  depraved. 

The  development  of  the  morbid  changes  which  take  place  in 
this  structure,  even  in  subjects  of  this  kind,  while  the  character 
of  the  disease  is  influenced,  if  not  determined,  by  a  specific  con- 
stitutional tendency,  is,  nevertheless,  referable  to  local  irrita- 
tion as  the  immediate  or  proximate  cause,  and,  were  this  the 
proper  place,  we  could  cite  numerous  cases  tending  to  establish 
the  truth  of  this  opinion. 

In  scrofulous  habits,  the  gums  have  a  pale  bluish  appearance, 
and  when  subjected  to  local  irritation,  they  become  flabby,  ex- 
hale a  nauseating  odor,  detach  themselves  from  the  necks  of  the 
teeth,  and  their  apices  grow  down  between  these  organs.  The 
blood  circulates  in  them  languidly,  and  debility  seems  to  pervade 
their  whole  substance.  They  are  exceedingly  irritable,  and  not 
unfrequently  take  on  aggravated  forms  of  disease,  and,  as  often 
happens  to  this,  as  well  as  to  the  preceding  habit,  there  are  com- 


CHARACTERISTICS   OF   THE  GUMS.  213 

bined  tendencies  which  favor  the  production  of  ill-conditioned 
tumors  and  ulcers. 

The  indications  furnished  by  the  gums  during  the  existence  of 
a  mercurial  diathesis  of  the  system,  are,  morbid  sensibility,  in- 
creased vascular  and  glandular  action,  foulness,  bleeding  from 
the  most  trifling  injuries,  pale,  bluish  appearance  of  their  sub- 
stance, turgidity  of  their  apices  and  sloughing.  The  eff"ects, 
however,  resulting  to  these  parts  from  the  employment  of  mer- 
cury differ  in  different  individuals  according  to  the  general  con- 
stitutional susceptibility,  the  quantity  taken  into  the  system,  and 
the  length  of  time  its  use  has  been  continued.  In  persons  of 
very  irritable  habits,  a  single  dose  will  sometimes  produce  ptya- 
lism,  and  so  increase  the  susceptibility  of  the  gums,  that  the 
secretions  of  the  mouth,  in  their  altered  state,  will  at  once  rouse 
up  a  morbid  action  in  them. 

The  effects  of  a  mercurial  diathesis  upon  these  parts,  is  not 
un frequently  so  great  as  to  result  in  the  loss  of  the  whole  of  the 
teeth.  But  with  these  effects  both  the  dental  and  medical  prac- 
titioner are  too  familiar  to  require  any  further  description. 

Finally,  we  would  observe,  that  the  indications  of  the  several 
characteristics  to  which  we  have  now  briefly  alluded,  may  not  be 
correct  in  every  particular,  and  there  are  others  which  we  have 
not  mentioned;  yet  we  think  they  will  commonly  be  found  true. 
As  a  general  rule,  persons  of  a  full  habit,  though  possessed  of 
mixed  temperaments  and  in  the  enjoyment  of  what  is  usually 
called  good  health,  have  gums  well  colored,  with  rather  thick 
margins,  and  very  susceptible  to  local  irritation.  With  this  de- 
scription of  individuals,  inflammation,  turgidity,  and  suppuration 
of  the  gums  are  very  common.  To  prevent  these  effects,  con- 
stant attention  to  the  cleanliness  of  the  teeth  is  indispensable. 

Professor  Schill  says,  the  "  gum  is  pale  in  chlorosis  and  anae- 
mia ;  of  a  purple  red  color  before  an  active  hemorrhoidal  dis- 
charge, and  in  cases  of  dysmenorrhoea  ;  of  a  dark  red  color, 
spongy,  and  bleeding  readily  in  scurvy  and  diabetes  mellitus, 
and  after  the  use  of  mercury.  Spoqgy  growths  indicate  caries 
of  the  subjacent  bone."* 

Regular  periodical  bleedings  of  the  gums  in  dysmenorrhoea, 

*  Outlines  of  Pathological  Senieiolof/y,  page  168,  of  the  Select  Medical  Library  edi- 
tion. 


214  CHARACTERISTICS    OF   THE    GUMS. 

and  particularly  in  scorbutic  and  mucous  subjects,  are  not  un- 
frequent,  nor  in  any  case  where  they  are  in  a  turgid  condition. 

Spongy  growths  of  the  gums  in  scorbutic  and  scrofulous  per- 
sons, often  result  from  irritation  produced  by  decayed  teeth,  and 
are  not,  therefore,  always  to  be  regarded  as  an  indication  of 
caries  of  the  subjacent  bone. 

Dr.  T.  Thompson,  of  London,  says,  that  the  reflected  margin 
of  the  gums  of  a  large  majority  of  phthisical  patients,  is  deeper 
in  color  than  the  other  portions,  usually  presenting  a  vermilion 
tint.* 

Mr.  George  Waite  says,  "A  change  of  residence  to  a  damp 
climate  will  often  rouse  up  in  the  gums  a  great  degree  of  vascu- 
larity. In  the  damp  places  of  England  and  Ireland  the  appear- 
ances which  the  gums  present  are  of  a  turgid  and  vascular  na- 
ture. In  the  damp  countries  of  France,  these  conditions  of  the 
gums  run  a  much  greater  length  from  the  circumstance  of  the 
difi'erence  in  the  constitutions  of  the  two  nations.  In  the  damps 
of  Germany  and  Switzerland,  persons  also  lose  their  teeth  early 
in  life,  the  climate  engenders  malaria  and  low  fevers,  enfeebles 
the  power  of  digestion,  and  brings  on  rheumatic  aflfections  with 
languor  and  general  constitutional  debility." 

Of  the  correctness  of  Mr.  Waite's  observations  there  can  be 
no  question,  and  they  go  to  establish  what  has  been  said  in  re- 
gard to  the  predisposing  cause  of  disease  in  the  gums  ;  namely, 
that  the  enervation  of  the  vital  powers  of  the  body,  from  what- 
ever cause  produced,  increases  their  susceptibility  to  morbid  im- 
pressions. 

*  Clinical  Lectures  on  Pulmonary  Consumption,  p.  117. 


CHAPTEH    FOURTH. 
PHYSICAL  CHARACTERISTICS  OF  SALIVARY  CALCULUS. 

The  color,  consistence,  and  quantity  of  salivary  calculus  or 
tartar,  as  it  is  most  commonly  called,  vary  in  different  tempera- 
ments, and  upon  all  of  them  the  state  of  the  general  health  ex- 
ercises considerable  influence.  The  characteristics  of  this  sub- 
stance, therefore,  furnish  diagnoses,  important  both  to  the  phy- 
sician and  dentist.  Their  indications  are  in  many  cases  less 
equivocal  than  the  appearances  of  any  other  part  of  the  mouth ; 
but,  like  those  of  the  gums,  should  not  perhaps,  be  alone  relied 
upon.  It  is  necessary  to  interrogate  every  part  from  which  in- 
formation can  be  derived  concerning  the  pathological  condition 
of  the  several  organs  of  the  body. 

Salivary  calculus  is  composed  of  earthy  salts  and  animal  mat- 
ter. Phosphate  of  lime  and  fibrine,  or  cartilage,  are  its  prin- 
cipal ingredients  ;  a  small  quantity  of  animal  fat,  however,  enters 
into  its  composition,  and  the  relative  proportions  of  its  constitu- 
ents vary  accordingly  as  it  is  hard  or  soft,  or  as  the  temperament 
of  the  individual  from  whose  mouth  it  is  taken,  is  favorable  or 
unfavorable  to  health ;  hence  it  is,  that  the  analyses  that  have 
been  made  of  it  by  different  chemists,  differ.  No  two  give  the 
same  result. 

The  black,  dry  tartar,  deposited  around  the  necks  of  the  teeth 
of  such  only  as  have  good  constitutions,  is  never  in  large  quan- 
tity ;  it  is  dissolved  in  muriatic  acid  with  difficulty,  while  the  dry 
light  brown  tartar  found  upon  the  teeth  of  bilious  persons,  dis- 
solves more  readily  in  it ;  but  the  soft  white  tartar,  found  upon 
the  teeth  of  individuals  of  mucous  temperaments,  is  scarcely  at 
all  soluble  in  the  acids,  but  is  readily  dissolved  in  the  alkalies.* 

All  persons  are  subject  to  salivary  calculus,  but  not  alike  ;  it 
collects  on  the  teeth  of  some  in  larger  quantities  than  on  those 
of  others,  and  its  chemical  and  physical  characteristics  are  ex- 

*  See  M.  Delabarre's  Traite  de  la  Seconde  Dentition. 


216  CHARACTERISTICS    OF    SALIVARY    CALCULUS. 

ceedingly  variable.  It  is,  sometimes,  almost  wholly  composed 
of  calcareous  ingredients ;  at  other  times,  these  constitute  but 
about  one-half,  or  little  more  than  one-half  of  its  substance,  the 
remainder  being  made  up  of  animal  matter.  Nor  is  its  color 
more  uniform.  Sometimes  it  is  black,  at  other  times  it  is  of  a 
dark,  pale,  or  yellowish  brown,  and  in  some  instances  it  is  nearly 
white.  It  also  differs  in  density.  In  the  mouths  of  some  it  has 
a  solidity  of  texture  nearly  equal  to  that  of  the  teeth  themselves, 
in  others,  it  is  so  soft  that  it  can  be  scraped  from  the  teeth  with 
the  thumb  or  finger  nail.  The  black  kind  is  the  hardest,  the 
white  the  softest,  and  its  density  is  increased  or  diminished  as  it 
approaches  the  one  or  the  other  of  these  colors. 

Salivary  calculus  collects  in  very  small  quantities  on  the  teeth 
of  persons  possessed  of  the  most  perfect  constitution,  and,  even 
on  these  it  is  seldom  found,  except  on  the  inner  surfaces  of  the 
lower  incisors  next  the  gums.  It  is  then  black,  or  of  a  dark 
brown  ;  very  dry,  and  almost  as  hard  as  the  teeth,  to  which  it 
adheres  with  great  tenacity. 

It  rarely  happens  that  any  unpleasant  effects  are  produced  by 
the  presence  of  this  kind  of  tartar  upon  the  teeth.  The  general 
health  is  never  affected  by  it,  and  the  only  local  injury  that  re- 
sults from  it,  is  slight  turgidity  of  the  edge  of  the  gums  in  im- 
mediate contact  with  it. 

The  indications,  therefore,  of  this  description  of  tartar,  are 
favorable,  both  with  regard  to  the  teeth,  gums  and  organism 
generally.  The  teeth  upon  which  it  is  found  are  of  an  excellent 
quality  and  rarely  affected  by  caries.  They  have  the  character- 
istics represented  as  belonging  to  the  best  kind,  and  teeth  of  this 
description  are  only  found  among  persons  having  good  innate 
constitutions. 

There  is  another  kind  of  black  tartar,  differing  from  this  in 
many  particulars.  It  is  found  in  the  mouths  of  those  having 
good  constitutions,  but  whose  physical  powers  have  been  ener- 
vated by  privation  or  disease,  or  intemperance  and  debauchery, 
and  most  frequently  by  the  last  named.  It  is  found  in  large 
quantities  on  the  teeth  opposite  the  mouths  of  the  salivary  ducts ; 
it  is  exceedingly  hard,  and  agglutinated  so  firmly  to  the  organs, 
that  it  is  removed  with  great  difficulty ;  it  is  very  black  ;  has  a 
rough  and  uneven  surface,  and  is  covered  with  a  glairy,  viscid, 
and  almost  insufferably  offensive  mucus. 


I 


CHARACTERISTICS    OF    SALIVARY    CALCULUS.  217 

The  presence  of  this  kind  of  salivary  calculus  is  attended  with 
very  hurtful  consequences,  not  only  to  the  gums,  alveolar  pro- 
cesses and  teeth,  but  also  to  the  general  health.  It  causes  the 
gums  to  inflame,  swell,  suppurate  and  recede  from  the  teeth, 
the  alveoli  to  waste,  and  the  teeth  to  loosen  and  frequently  to 
drop  out.  The  secretions  of  the  mouth  are  also  vitiated  by  it, 
and  rendered  unfit  to  be  taken  into  the  stomach.  Hence,  as 
long  as  it  is  permitted  to  remain  on  the  teeth,  neither  the  skill 
of  the  physician,  nor  the  best  regulated  regimen,  though  they 
may  afford  partial  and  temporary  relief,  will  fully  restore  to  the 
system  its  healthy  functions. 

As  this  kind  of  tartar  is  seldom  if  ever  met  with  except  in  con- 
stitutions naturally  excellent,  the  teeth  on  which  it  is  deposited 
are  generally  sound,  but  they  are  often  caused  by  the  disease 
which  is  produced  in  the  gums  and  alveoli,  to  loosen  and  drop  out. 

The  dark  brown  tartar  is  not  so  hard  as  either  of  the  descrip- 
tions of  black.  It  sometimes  collects  in  tolerably  large  quanti- 
ties on  the  lower  front  teeth,  and  on  the  first  and  second  superior 
molars ;  it  is  also  often  found  on  all  the  teeth,  though  not  in  as 
great  abundance  as  on  these.  It  does  not  adhere  with  as  much 
tenacity  as  either  of  the  preceding  kinds,  and  can  be  more  easily 
detached  from  them.  It  exhales  a  more  fetid  odor  than  the  first 
variety,  but  is  less  offensive  than  the  second. 

The  persons  most  subject  to  this  kind  of  tartar,  are  of  mixed 
temperaments — the  sanguineous,  however,  almost  always  predomi- 
nating. They  may  be  denominated  sanguineo-serous  and  bilious. 
Their  physical  organization,  though  not  the  strongest  and  most 
perfect,  may,  nevertheless,  be  considered  very  good.  But,  being 
more  susceptible  to  morbid  impressions,  their  general  health  is 
less  uniform,  and  more  liable  to  impairment  than  those  possessed 
of  the  most  perfect  constitutions. 

The  effects  arising  from  accumulations  of  this  description  of 
salivary  calculus,  both  local  and  constitutional,  are  less  hurtful 
than  the  variety  last  noticed  ;  but  like  that,  it  causes  the  gums  to 
inflame,  swell,  suppurate,  and  to  retire  from  and  expose  the  necks 
of  the  teeth,  the  alveoli  to  waste,  the  teeth  to  loosen  and  some- 
times to  drop  out.  It  also  gives  rise  to  a  vitiated  condition  of 
the  fluids  of  the  mouth. 

Salivary  calculus  of  a  light  or  pale  yellowish  brown  color,  is 
15 


218  CHARACTERISTICS   OF    SALIVARY    CALCULUS. 

of  a  much  softer  consistence  than  the  darker  varieties,  and  is 
seldom  found  upon  the  teeth,  except  of  persons  of  hilious  tem- 
perament, or  those  in  whom  this  predominates.  It  has  a  rough 
and,  for  the  most  part,  a  dry  surface ;  it  is  found  in  large  quan- 
tities opposite  the  mouths  of  the  salivary  ducts,  and  sometimes 
every  tooth  in  the  mouth  is  completely  imbedded  in  it.  It  con- 
tains less  of  the  earthy  salts  and  more  of  the  animal  matter  than 
any  of  the  foregoing  descriptions,  and  from  the  quantity  of 
vitiated  mucus  in  and  adhering  to  it,  has  an  exceedingly  oifen- 
sive  smell.  It  is,  sometimes,  though  not  always,  so  soft  that  it 
may  be  crumbled  between  the  thumb  and  finger. 

Inflammation,  turgescence  and  suppuration  of  the  gums,  in- 
flammation of  the  alveolo-dental  periosteum,  the  destruction  of 
the  sockets  and  loss  of  the  teeth,  and  an  altered  condition  of  the 
fluids  of  the  mouth,  are  among  the  local  effects  produced  by  the 
long  continued  presence  of  large  collections  of  this  variety  of 
tartar.  The  constitutional  effects  are  not  much  less  pernicious. 
Indigestion  and  general  derangement  of  all  the  assimilative  func- 
tions are  among  the  most  common.  When  the  deposit  is  not 
large,  inflammation  and  spongincss  of  such  parts  of  the  gums  as 
are  in  immediate  contact  with  it,  and  fetid  breath,  are  the  prin- 
cipal of  the  unpleasant  effects  produced  by  it. 

White  tartar  rarely  collects  in  very  large  quantities,  and 
though  most  abundant  on  the  outer  surfaces  of  the  first  and 
second  superior  molars,  and  the  inner  surfaces  of  the  lower  in- 
cisors, it  is  nevertheless  frequently  found  on  all  the  teeth.  Its 
calcareous  ingredients  are  less  abundant  than  those  of  any  of  the 
preceding  descriptions.  Fibrin,  animal  fat,  and  mucus,  con- 
stitute by  far  the  larger  portion  of  its  substance.  It  is  very 
soft,  seldom  exceeding  in  consistence  common  cheese  curd,  to 
which  in  appearance  it  bears  considerable  resemblance.  Although 
it  exerts  but  little  mechanical  irritation  upon  the  gums,  it  keeps 
up  a  constant  morbid  action  in  them.  Its  effects,  however, 
upon  the  teeth,  are  far  more  deleterious  than  any  other  descrip- 
tion of  tartar.  It  corrodes  the  enamel,  and  causes  rapid  decay 
of  the  organs.     The  fluids  of  the  mouth  are  also  vitiated  by  it. 

It  is  only  upon  the  teeth  of  persons  of  mucous  habit,  or  those 
who  have  suffered  from  diseases  of  the  mucous  membranes,  or 


CHARACTERISTICS  OF  SALIVARY  CALCULUS.       219 

those  in  whom  these  tissues  have  been  more  or  less  involved,  that 
this  kind  of  tartar  accumulates. 

There  is  one  other  kind  of  tartar  described  by  dental  writers. 
It  is  of  a  dark  green  color,  and  is  seen  more  frequently  on  the 
anterior  surfaces  of  the  upper  teeth  occupying  the  front  part  of 
the  mouth,  than  on  any  of  the  others.  It  resembles  more  closely 
a  stain  on  the  enamel  than  salivary  calculus.  Children  and 
young  persons  are  more  subject  to  it  than  adults,  though  it  is 
occasionally  observed  on  the  teeth  of  the  latter.  It  is  exceed- 
ingly acrid,  and  has  the  eflFect  of  decomposing  the  enamel ;  the 
margins  of  the  gums  around  the  teeth  having  it  on  them  are  in- 
flamed, and  the  sanguineous  capillaries  of  their  whole  substance 
appear  to  be  distended  and  more  than  ordinarily  languid. 

This  kind  of  discoloration  of  the  enamel  is  indicative  of  an 
irritable  condition  of  the  mucous  membranes  and  viscidity  of  the 
fluids  of  the  mouth.  Sour  eructations,  vomitings,  diarrhoea  and 
dysentery  are  not  unfrequent  with  those  whose  teeth  are  thus 
affected. 

For  the  chemical  constituents  of  salivary  calculus,  the  reader 
is  referred  to  a  subsequent  chapter,  where,  also,  the  morbid 
effects  produced  by  its  several  varieties  are  treated  of  more  at 
length. 


CHAPTER    FIFTH. 

PHYSICAL  CHARACTERISTICS  OF  THE  FLUIDS  OF  THE 

MOUTH. 

In  treating  upon  the  physical  characteristics  of  the  fluids  of 
the  mouth,  it  will  not  be  necessary  to  dwell  at  much  length  on 
their  effects,  when  in  a  morbid  condition,  on  this  cavity.  Con- 
cerning their  agency  in  the  production  of  caries  of  the  teeth,  we 
shall  add  one  or  two  remarks. 

Saliva,  in  healthy  persons  having  good  constitutions,  has  a 
light  frothy  appearance,  and  but  little  viscidity.  Inflammation 
of  the  gums,  from  whatever  cause  produced,  increases  its  viscid- 
ity, and  causes  it  to  be  less  frothy.  In  a  healthy  state,  it  is  in- 
odorous, floats  upon  and  mixes  readily  with  water,  but  when  in 
a  viscid  or  diseased  condition,  it  sinks  and  mixes  with  it  with 
difficulty. 

Irritation  in  the  mouth,  from  diseased  gums,  aphthous  ulcers, 
inflammation  of  the  mucous  membrane,  the  introduction  of  mer- 
cury into  the  system,  or  taking  any  thing  pungent  into  the 
mouth,  increases  the  flow  of  this  fluid,  and  causes  it  to  be  more 
viscid  than  it  is  in  its  natural  and  healthy  state. 

In  treating  on  the  symptomatology  of  saliva,  Prof.  Schill  says, 
"The  sympathetic  affection  of  the  stomach  in  pregnancy  is  some- 
times accompanied  by  salivation,  which,  in  this  case,  mostly  takes 
place  after  conception,  and  sometimes  continues  to  the  time  of 
delivery.  It  is  also  observed  to  occur  in  weakened  digestion,  in 
gastric  catarrhs,  after  the  use  of  emetics,  in  mania,  in  what  are 
called  abdominal  obstructions,  in  hypochondriasis  and  hysteria; 
salivation  occurs  during  the  use  of  mercury  or  antimony. 

"In  confluent  small-pox,  salivation  is  a  favorable  sign.  If  it 
cease  before  the  ninth  day  the  prognosis  is  bad.  In  lingering 
intermittents,  salivation  is  sometimes  critical;  more  frequently 
in  these  affections  it  precedes  the  termination  in  dropsy. 

"  Diminution  of  the  salivary  secretion,  and,  in  consequence  of 


CHARACTERISTICS    OF   THE    FLUIDS    OF   THE    MOUTH.        221 

this,  dryness  of  the  mouth,  is  peculiar  to  the  commencement  of 
acute  disease,  as  also  to  the  hectic  fevers  occasioned  by  affections 
of  the  abdominal  organs.  If  the  flow  of  the  saliva  stop  sud- 
denly, there  is  reason  to  apprehend  an  affection  of  the  brain. 

"Thick  viscid  saliva  occurs  under  the  same  circumstances  as 
the  diminution  of  the  salivary  secretion,  especially  in  small-pox, 
typhus,  and  in  hectic  fevers.  It  is  thin  in  ptyalism.  In  gastric 
diseases,  where  the  liver  participates,  it  becomes  yellow  or  green  ; 
by  the  admixture  of  blood  it  may  assume  a  reddish  color ;  in 
pregnant  or  lying-in  women,  it  is  sometimes  milky ;  an  icy  cold 
saliva  was  observed  by  the  author  in  face-ache. 

"  Frothy  saliva  from  the  mouth  is  observed  in  apoplexy,  epi- 
lepsy, hydrophobia,  and  in  hysterical  paroxysms."* 

Dr.  Bell,  of  Philadelphia,  in  a  note  to  the  work  from  which 
we  have  just  quoted,  says,  "  Acid  saliva  is  regarded  by  M.  Donnd, 
as  indicative  of  gastritis  or  deranged  digestion.  Mr.  Laycock," 
he  observes,  "on  the  other  hand,  infers  from  numerous  experi- 
ments on  hospital  patients,  that  the  saliva  may  be  acid,  alkaline, 
or  neutral,  when  the  gastric  phenomena  are  the  same.  In  gene- 
ral, Mr.  L.  remarked,  that  it  was  alkaline  in  the  morning  and 
acid  in  the  evening." 

We  have  had  occasion  to  observe,  that  the  acid  quality  of  the 
saliva  was  more  apparent  and  more  common  in  lymphatic,  mu- 
cous and  bilious  dispositions,  than  in  sanguineous  or  in  sanguineo- 
serous  persons,  and  that  weakened  or  impaired  digestion  always 
had  a  tendency  to  increase  it. 

M.  Delabarre  says,  "When  this  fluid"  (the  saliva)  "has  re- 
mained in  the  mouth  some  moments,  it  there  obtains  new  proper- 
ties, according  to  each  individual's  constitution  and  the  integrity 
of  the  mucous  membrane,  or  some  of  the  parts  which  it  covers. 

"  In  subjects  who  enjoy  the  best  health,  whose  stomach  and 
lungs  are  unimpaired,  the  saliva  appears  very  scarce,  but  this  is 
because  it  passes  into  the  stomach  almost  as  soon  as  it  is  fur- 
nished by  the  glands  that  secrete  it.  It  only  remains  long 
enough  in  the  mouth  to  mix  with  a  small  quantity  of  mucus,  and 
absorb  a  certain  portion  of  atmospheric  air,  to  render  it  frothy. 

"  On  the  other  hand,  the  saliva  of  an  individual  whose  mucous 

*  Outlines  of  Pathological  Semeiology  ;  edition  of  the  Select  Medical  Library,  pp. 
173-4, 


222        CHARACTERISTICS    OF    THE    FLUIDS    OF    THE    MOUTH. 

system  furnishes  a  large  quantity  of  mucus,  is  stringy  and  heavy : 
is  but  slightly  charged  with  oxygen,  contains  a  great  proportion 
of  azote  and  sulphur,  and  stains  silver."* 

Increased  redness  and  irritability  of  the  mucous  membrane  of 
the  mouth,  is  an  almost  invariable  accompaniment  of  general 
acidity  of  these  fluids.  Excoriation  and  aphthous  ulcers,  and 
bleeding  of  the  gums,  also,  frequently  result  from  this  condition 
of  the  salivary  and  mucous  secretions  of  this  cavity. 

Anorexia,  languor,  general  depression  of  spirits,  head-ache, 
diarrhoea,  and  rapid  decay  of  the  teeth,  are  very  common  among 
persons  habitually  subject  to  great  viscidity  of  the  buccal  fluids. 
It  is  likewise  among  subjects  of  this  kind,  and  particularly  when 
the  viscidity  is  so  great  as  to  cause  clamminess  of  these  secre- 
tions, that  the  green  discoloration  of  the  enamel  of  the  teeth  is 
most  frequently  met  with. 

*  Vide  Traits  de  la  Seconde  Dentition, 


CHAPTER    SIXTH. 
PHYSICAL  CHARACTERISTICS  OF  THE  LIPS. 

The  indications  of  the  physical  characteristics  of  the  lips  are 
more  general  than  local,  and  the  observations  of  Laforgue  and 
Delabarre  on  this  subject,  leave  little  to  be  added.  We  cannot, 
therefore,  do  much  more  than  repeat  what  they  have  said. 

"The  lips,"  says  Delabarre,  "present  marked  differences  in 
different  constitutions.  They  are  thick,  red,  rosy  or  pale, 
according  to  the  qualities  of  the  blood  that  circulates  through 
their  arteries." 

Firmness  of  the  lips,  and  a  pale  rose  color  of  the  mucous 
membrane  that  covers  them,  are,  according  to  Laforgue,  indica- 
tive of  pure  blood,  and,  as  a  consequence,  of  a  good  constitution. 
Redness  of  the  lips,  deeper  than  that  of  the  pale  rose,  is  also 
mentioned  as  one  of  the  signs  of  sanguineo-serous  blood.  Soft, 
pale  lips  are  indicative  of  lymphatico-serous  dispositions.  In 
these  subjects  the  lips  are  almost  entirely  without  color.  When 
there  is  a  sufficiency  of  blood  the  lips  are  firm,  though  variable 
in  color,  according  to  the  predominancy  of  the  red  or  serous 
parts  of  this  fluid. 

Both  hardness  and  redness  of  the  lips,  and  all  the  soft  parts 
of  the  mouth,  are  enumerated  among  the  signs  of  plethora. 
Softness  of  the  lips,  without  change  of  color  in  their  mucous 
membrane,  is  spoken  of  by  the  last  author  as  indicative  of  defi- 
ciency of  blood;  and  softness  and  redness  of  the  mucous  mem- 
brane of  the  lips  are  signs  that  the  blood  is  small  in  quantity 
and  sanguineo-serous. 

Deficiency  in  the  red  corpuscles,  and  in  the  nutritive  qualities 
of  the  blood,  is  evidenced  by  the  want  of  color  and  softness 
of  the  lips,  and  general  paleness  of  the  mucous  membrane  of 
the  whole  mouth.  "The  fluids  contained  in  the  vessels,"  says 
Laforgue,  "  in  forms  of  anaemia,  yield  to  the  slightest  pres- 


224  CHARACTERISTICS    OF   THE   LIPS. 

sure,  and  leave  nothing  between  the  fingers  but  the  skin  and 
cellular  tissue." 

In  remarking  upon  the  signs  of  the  dififerent  qualities  of  the 
blood,  the  above  mentioned  author  asserts  that  the  constitution 
of  children,  about  six  years  of  age,  cannot  be  distinguished  by 
any  universal  characteristic;  but  that  the  lips,  as  well  as  the 
other  parts  of  the  mouth,  constantly  betoken  "the  quality  of 
blood  and  that  of  the  flesh;"  and,  "consequently,  they  proclaim 
health  or  disease,  or  the  approach  of  asthenic  and  adynamic 
disorders,  which  the  blood  either  causes  or  aggravates." 

Again,  he  observes,  that  the  blood  of  all  children  is  "  super- 
abundantly serous,"  but  that  it  is  redder  in  those  of  the  second 
constitution  than  in  those  of  any  of  the  others ;  and  that  this  is 
more  distinctly  indicated  by  the  color  of  the  lips.  "  This  quality 
of  the  blood,"  says  he,  "is  necessary  to  dispose  all  the  parts  to 
elongate  in  their  growth.  When  the  proportions  of  the  consti- 
tuent elements  of  the  blood  are  just,  growth  is  accomplished 
without  disease.  If  the  proportions  are  otherwise  than  they 
should  be  for  the  preservation  of  the  health,  or  if  one  or  more  of 
its  elements  be  altered,  health  no  longer  exists,  growth  is  arrested 
altogether,  or  is  performed  irregularly.  The  nutritive  matter  is 
imperfect — assimilation  is  prevented  or  impaired.  On  the  other 
hand,  its  disintegration  decomposes  the  patient;  if  death  does 
not  sooner  result,  it  will  consume  him  by  the  lesion  of  some  vital 
organ.   * 

The  changes  produced  in  the  color  of  the  blood  by  organic 
derangement  are  at  once  indicated  by  the  color  of  the  lips. 

The  accuracy  of  Laforgue's  observations  on  the  indications 
of  the  physical  characteristics  of  the  lips,  has  been  fully  con- 
firmed by  subsequent  writers.  Delabarre,  in  his  remarks  on  the 
semeiology  of  the  mouth,  has  added  nothing  to  them. 

"The  secretion  of  the  lips,"  says  Professor  Schill,  "has  a 
similar  diagnostic  and  prognostic  import  to  that  of  the  tongue 
and  gums.  They  become  dry  in  all  fevers  and  in  spasmodic 
paroxysms.  A  mucous  white  coating  is  a  sign  of  irritation  or 
inflammation  of  the  intestinal  canal;  accordingly,  this  coating 
is  found  in  mucous   obstructions,  in  gastric  and  intermittent 

*  Vide  Semeiologie  Buccale  et  Buecamancie. 


CHARACTERISTICS   OF   THE   LIPS.  225 

fevers,  in  mucous  fever,  and  before  a  gouty  paroxysm.  A  dry 
brown  coating  of  the  lips  is  a  sign  of  colliquation  in  consequence 
of  typhus  affections;  it  is  accordingly  observed  in  typhus,  in 
putrid  fever,  in  acute  exanthemata,  and  inflammations  which 
have  become  nervous."* 

The  lips,  however,  do  not  present  so  great  a  variety  of  appear- 
ances as  those  of  other  parts  of  the  mouth,  for  the  reason  that 
they  are  not  as  subject  to  local  diseases;  but  their  general  patho- 
logical indications  are,  perhaps,  quite  as  decided. 

*  Vide  PatJiological  Semeiology,  p.  152. 


CHAPTER    SEVENTH. 
PHYSICAL  CHARACTERISTICS  OF  THE  TONGUE. 

The  appearance  of  the  tongue,  both  in  health  and  disease,  is 
regarded  by  physicians  as  furnishing  more  correct  indications 
of  the  state  of  the  constitution  and  general  health  than  any  of 
the  other  parts  of  the  mouth.  It  is  asserted,  however,  by  others, 
and  by  those,  too,  who  have  the  very  best  opportunities  for  in- 
specting the  various  parts  of  this  cavity,  that  the  lips  and  gums 
furnish  as  marked  and  reliable  indications  as  the  tongue.  That 
the  state  and  quality  of  the  blood  can  be  as  readily  ascertained 
by  an  examination  of  these  parts,  as  by  that  of  the  tongue,  is, 
we  believe,  undeniable ;  but  that  the  pathological  condition  of  the 
body  can  be  inferred  is  a  question  we  leave  for  others  to  decide. 

So  far  as  the  quality  of  the  blood  and  the  temperament  of 
the  subject  are  indicated  by  the  color  of  the  tongue,  the  preced- 
ing remarks  concerning  the  lips  will  be  found  applicable.  The 
one  being  as  much  influenced  by  them  as  the  other.  It  will, 
therefore,  be  unnecessary  to  recapitulate  what  we  have  before 
said  upon  the  subject. 

The  effects  produced  upon  the  mucous  membrane  of  the  tongue 
by  disease  in  any  other  part,  are  said  to  be  analogous  to  those 
produced  on  the  general  integument.  So,  also,  are  the  changes 
of  its  color,  consistence,  humidity  and  temperature  similar  to 
those  of  the  skin.  We  are  likewise  told  that  the  changes  of  its 
coating  agree  with  the  analogous  changes  of  the  perspiration, 
and  that  these  phenomena  are  more  decided  in  acute  than  in 
chronic  affections.* 

But  the  diagnostic  and  prognostic  indications  of  the  tongue 
vary  according  to  the  temperament  and  constitutional  predispo- 
sition of  the  individual.  The  physician  should  acquaint  himself 
with  its  appearances  in  health,  to  be  able  to  determine  correctly 
its  indications  in  disease.     He  should  likewise  inform  himself  of 

*  Vide  Professor  Schill's  Semeiology. 


CHARACTERISTICS    OF   THE    TONGUE.  227 

the  changes  produced  in  its  appearance  by  certain  morbid  con- 
ditions of  the  body.  In  some  subjects  it  is  always  slightly 
furred  and  rather  dry,  especially  near  its  root;  in  others  it  is 
always  clean  and  humid;  in  some,  again,  it  is  always  red,  and  in 
others  pale. 

Professor  Schill  divides  the  signs  of  the  tongue  into  objective 
and  subjective.  "  To  the  objective  belong  the  changes  of  size, 
form,  consistence,  color,  temperature,  secretion,  and  of  power 
and  direction  of  motion  ;  and  to  the  subjective  belong  the  anoma- 
lous sensations  of  taste." 

In  enumerating  the  pathognomonic  signs  of  the  tongue,  this 
author  says  that  hypertrophy,  inflammation  or  congestion,  may 
occasion  its  enlargement;  and  that  inflammatory  swelling  of  it, 
when  arising  from  acute  diseases,  such  as  "angina,  pulmonary 
inflammation,  measles,  plague,  or  variola,  yields  an  unfavorable 
prognosis.  Even  non-inflammatory  swelling  of  the  tongue  is  a 
dangerous  phenomenon  in  acute  diseases,  especially  cerebral, 
which  are  combined  with  coma.  If  it  be  the  consequence  of 
mercury,  of  the  abuse  of  spirtuous  drinks,  of  gastric  inflamma- 
tion, of  chlorosis,  of  syphilis,  or  if  it  occur  in  hysteria  or  epilepsy, 
the  prognosis  is  not  dangerous;  but  the  disease  is  always  the 
more  tedious  where  the  tongue  swells  than  where  it  does  not. 
It  is  enlarged,  also,  by  degeneresceuce  and  cancer." 

"Diminution  of  the  size  of  the  tongue  takes  place  where 
there  is  considerable  emaciation.  In  this  case  it  continues  soft 
and  movable.  If,  in  acute  states,  the  tongue  becomes  small,  and 
is,  at  the  same  time,  hard,  retracted  and  pointed,  the  irritation 
is  very  great,  and  the  prognosis  bad.  This  sign  occurs  more 
especially  in  typhus,  in  the  oriental  cholera,  in  inflammation  of 
the  lungs,  and  in  acute  cerebral  affections.  In  hysteria  and 
epilepsy  this  phenomenon  has  no  unfavorable  import." 

Internal  maladies,  he  says,  seldom  cause  the  form  of  the 
tongue  to  change;  but  that  the  simplest  change  arising  from 
chronic  irritations  of  the  stomach,  chronic  dyspepsia,  and  acute 
exanthemata,  is  enlargement  of  its  papillae.  In  cases  of  pro- 
tracted dyspepsia,  the  edges  of  the  tongue  sometimes  crack,  and 
in  paralysis  and  epilepsy,  it  becomes  elongated. 

In  acute  diseases,  a  soft  tongue  is  a  favorable  indication ;  and 
flaccidity  of  it  is  symptomatic  of  debility. 


228  CHARACTERISTICS    OF   THE    TONGUE. 

Humidity  of  the  tongue,  he  tells  us,  is  a  favorable  sign,  and 
that  dryness  of  it  occurs  in  acute  or  violent  inflammations  and 
irritations,  and  more  particularly  when  seated  in  the  intestinal 
canal  and  respirator}'-  organs.  "  This  also  happens  in  diarrhoea, 
typhus,  pneumonia,  gangrene  of  the  lung,  pleuritis,  peritonitis, 
enteritis,  catarrhus  gastricus,  gastritis,  inflammation  of  joints, 
etc.  Among  the  higher  degrees  of  dryness,  he  enumerates  the 
rough,  the  fissured  and  burnt  tongue,  as  furnishing  still  more 
unfavorable  indications ;  informing  us,  at  the  same  time,  that  if 
these  be  not  accompanied  by  thirst,  they  prognosticate  a  fatal 
termination.  The  abatement  and  crisis  of  the  disease  is  indi- 
cated by  the  tongue  becoming  moist." 

Dr.  Bell,  of  Philadelphia,  in  a  note  to  Professor  Schill's 
observations  on  the  tongue,  says,  "  A  rough  and  dry,  and  even 
furred  tongue,  is  seen  in  some  dyspeptic  persons,  who  sleep  with 
the  mouth  open ;  and  although  it  indicates  an  irritation  of  the 
digestive  organs,  it  is  not  a  bad  augury."  Bilious  persons, 
not  unfrequently,  though  not  troubled  with  any  manifest  symp- 
toms of  gastric  or  intestinal  derangement,  or  any  other  apparent 
functional  disturbance,  have  a  furred  tongue  in  the  morning. 

Paleness  of  the  tongue,  says  Professor  Schill,  is  a  sign  of  a 
serous  condition  of  the  blood,  of  chlorosis,  of  great  loss  of  blood, 
of  chronic  disorders,  of  sinking  of  the  strength  in  acute  mala- 
dies, assuming  a  "  nervous  form,  as  typhus  and  scarlatina 
maligna.  It  is  also  found,"  says  he,  "in  enteritis  and  dysen- 
tery, when  but  little  fever  is  present."  He  infers  from  this, 
that  paleness  of  the  tongue  is  caused  by  the  "  drawing  of  the 
fluids  downward;"  but  it  is  often  observed  in  persons  who  enjoy 
tolerably  good  health.  Lymphatic  dispositions,  as  has  been 
before  remarked,  are  peculiarly  subject  to  it. 

Again,  he  observes,  that  a  very  red  tongue  is  indicative  of 
"violent  inflammation,  mostly  of  the  intestinal  canal,  but  also  of 
the  lungs  and  pharynx ;  also  of  acute  exanthemata."  He  regards 
the  prognosis  as  bad,  when  a  furred  tongue  "  in  acute  diseases 
of  the  intestinal  canal  becomes  clean  and  very  red,"  if  the  change 
is  not  accompanied  with  the  return  of  the  patient's  strength. 
"But,"  he  continues,  "if  the  debility  is  not  considerable,  and 
the  tongue  becomes  clean  and  very  red,  whilst  other  febrile 
symptoms  continue,  a  new  inflammation  may  be  expected."     But 


CHARACTERISTICS    OF   THE    TONGUE.  229 

even  in  affections  like  these,  the  redness  of  the  tongue  is  always 
more  considerable  in  sanguineous,  than  in  lymphatic  or  lymphatico- 
serous  subjects,  so  that  in  forming  a  prognosis  from  this  sign, 
the  temperament  of  the  individual  should  never  be  overlooked. 

Proceeding  with  the  description  of  the  signs  of  this  organ,  he 
says,  "  The  tongue  becomes  a  blackish-red  and  bluish-red  in  all 
serious  disturbances  of  the  circulation  and  respiration,  as  also  in 
severe  diseases  of  the  lungs  and  heart,  as  catarrhs,  suffocations, 
asthma,  extensive  inflammations  of  the  lungs,  carditis,  Asiatic 
cholera,  plague,  confluent  small-pox,  and  putrid  fevers.  It 
becomes  black  and  livid  in  cases  of  vitiation  of  the  blood,  more 
especially  in  scurvy,  at  the  setting  in  of  gangrene,  and  in 
phthisis,  when  death  is  near  at  hand." 

Among  the  diseases  mentioned  as  giving  rise  to  an  increase  of 
the  temperature  of  the  tongue,  are  glossitis,  violent  internal  in- 
flammation and  typhus  fever ;  and  coldness  of  this  organ  is 
observed  to  take  place  in  Asiatic  cholera,  and  at  the  approach  of 
death. 

The  signs  from  the  secretion  of  the  tongue  are  thus  enumerated : 
A  clean  and  moist  tongue  are  favorable  indications,  but  a  clean, 
dry  and  red  tongue,  as  seen  in  slow  nervous  fevers,  acute  ex- 
anthemata and  plague,  are  bad  auguries.  A  furred  or  coated 
tongue  is  said  to  occur  chiefly  in  intestinal  disorders,  diseases  of 
the  lungs,  skin,  and  in  rheumatic  affections.  The  coating  is  said 
to  vary  in  "color,  thickness,  adherence,  and  extent,"  and  differ- 
ent kinds  of  secretion  from  the  mucous  membrane  of  this  organ 
are  mentioned  as  occurring  in  different  diseases,  and  it  should 
have  been  added  in  the  same  disease  in  different  temperaments. 
After  describing  the  various  kinds  of  coating  on  the  tongue, 
together  with  their  respective  indications,  which  it  is  not  neces- 
sary here  to  enumerate,  the  occurrence  of  false  membranes  and 
pustules,  resulting  from  peculiar  forms  of  mucous  secretion,  are 
next  mentioned.  The  former  show  themselves  either  as  small 
white  points,  or  large  patches,  and  sometimes  they  are  said  to 
envelop  the  whole  tongue.  The  color  is  "  sometimes  white,  some- 
times yellow  and  sometimes  red,"  and  the  greater  the  surface 
covered  by  them,  the  more  unfavorable  is  the  prognosis  regarded. 
"Pustules  on  the  tongue,"  says  our  author,  "are  sometimes 
idiopathic,  but  in  most  cases  symptomatic.     They  are  either 


230  CHARACTERISTICS   OF   THE    TONGUE. 

distinct  or  confluent ;  the  confluent  are  the  worst.  Those  which 
are  hardish  and  dry,  and  also  those  which  are  blue,  and  those  of 
a  blackish  appearance,  which  sometimes  occur  in  acute  diseases, 
are  of  an  unfavorable  import."  On  the  other  hand,  those  which 
have  a  whitish,  soft,  moist,  and  semi-transparent  appearance,  are 
less  unfavorable,  and  when  the  aphthae,  or  eruption,  are  repeated, 
it  portends  a  longer  continuance  of  the  malady.  The  pustules 
or  aphthae  are  mentioned  as  being  frequent  accompaniments  to 
the  following  diseases :  namely,  gastritis,  catarrhs,  enteritis, 
metritis,  dysentery,  cholera  infantum,  peritonitis,  intermittent 
and  typhus  fevers,  pleuritis,  pneumonia,  and  the  third  stage  of 
pulmonary  consumption.  Their  prognosis  is  said  to  be  favorable, 
when  "  they  appear  with  critical  discharges  after  the  seventh 
day,"  and  unfavorable,  when  they  occur  as  a  consequence  of  a 
general  sinking  of  the  physical  powers  of  the  body.* 

But  it  is  unnecessary  to  enumerate  all  of  the  pathognomic 
indications  of  the  various  morbid  phenomena  described  by  semei- 
oloffists ;  we  have  noticed  more  of  them  than  was  our  intention 
to  have  done.  We  shall,  therefore,  conclude  the  present  inquiry, 
by  simply  observing,  that  the  indications  furnished  by  the 
physical  characteristics,  not  only  of  the  tongue,  but  by  those, 
also,  of  the  teeth,  the  gums,  salivary  calculus,  the  lips  and  fluids 
of  the  mouth,  are,  as  we  have  endeavored  to  show,  essential  to 
the  successful  exercise  of  the  duties  both  of  the  dental  and  medi- 
cal practitioner. 

*  Vide  Professor  Schill'a  Semeiology. 


PART    THIRD. 


DISEASES   OF   THE   TEETH  AND   THEIR 
TREATMENT. 


DISLOCATION  OF  THE  LOWER  JAW. 


PART  THIRD. 


DISEASES  OF  THE  TEETH. 

The  doctrine,  as  promulgated  by  Fox,  and,  subsequently,  ad- 
vocated by  Bell,  and  other  European  writers,  that  the  diseases 
of  the  teeth  are  the  same  as  those  which  attack  other  os- 
seous structures  of  the  body,  is  now  almost  universally  con- 
ceded to  be  incorrect.  With  the  exception  of  exostosis  and 
necrosis,  the  pathological  conditions  of  these  organs  do  not  bear 
the  slightest  analogy  to  those  of  other  bones.  They  are  not 
produced  by  the  same  causes,  nor  can  they  be  cured  by  the  same 
remedies. 

In  the  treatment  of  diseases  of  the  teeth  we  rely  mainly  upon 
art ;  in  diseases  of  other  osseous  tissues  the  resources  principally 
to  be  relied  on  are  found  in  the  recuperative  powers  of  the 
economy.  This  difference  is  clearly  seen  between  caries  in  the 
teeth  and  in  the  bones.  Nature  alone  can  repair  the  ravages  of 
the  one,  art  alone  of  the  other.  Exostosis,  which  is  a  disease 
common  to  bone  and  teeth,  is  found  only  in  the  cementum,  which 
is  the  connecting  link  between  dentine  and  osseous  tissue ;  whilst 
diseases  of  the  dentine  and  enamel  form  a  distinct  class,  requir- 
ing treatment  altogether  peculiar  to  themselves. 

The  teeth  are  more  liable  to  be  attacked  by  caries  than  by 
any  other  disease,  and  this,  therefore,  will  first  claim  our  atten- 
tion. 


16 


CHAPTER     FIRST. 
CARIES  OF  THE  TEETH. 

Caries  of  a  tooth  is  the  chemical  decomposition  of  the  earthy 
salts  of  the  affected  part,  sometimes,  but  not  always,  accompa- 
nied by  disorganization  of  the  animal  frame  work  of  this  portion 
of  the  organ.  There  is  no  affection  to  which  these  organs  are 
liable  more  frequent  in  its  occurrence,  or  fatal  in  its  tendency, 
than  this.  It  is  often  so  insidious  in  its  attacks,  and  rapid  in 
its  progress,  that  every  tooth  in  the  mouth  is  involved  in  irre- 
parable ruin,  before  even  its  existence  is  suspected. 

Its  presence  is  usually  first  indicated  by  an  opacjue  or  dark 
spot  on  the  enamel;  and,  if  this  be  removed,  the  subjacent  den-' 
tine  will  exhibit  a  black,  dark-brown  or  whitish  appearance.  It 
usually  commences  on  the  outer  surface  of  the  dentine  of  the 
crown,  beneath  the  enamel,  at  some  point  where  it  is  imperfect 
or  has  been  fractured  or  otherwise  injured ;  from  thence  it  pro- 
ceeds toward  the  centre  of  the  tooth,  increasing  in  circumfer- 
ence, until  it  reaches  the  pulp-cavity. 

If  the  diseased  part  is  of  a  soft  and  humid  character,  the 
enamel,  after  a  time,  usually  breaks  jn,  disclosing  the  ravages 
the  disease  has  made  on  the  subjacent  dentine.  But  this  does 
not  always  happen ;  the  form  of  the  tooth  sometimes  remains 
nearly  perfect,  until  its  whole  interior  structure  is  destroyed. 

No  portion  of  the  crown  or  neck  of  a  tooth  is  exempt  from 
this  disease ;  yet,  some  parts  are  more  liable  to  be  first  attacked 
than  others;  as,  for  example,  the  depressions  in  the  grinding 
surfaces  of  the  molars  and  bicuspids,  the  approximal  surfaces  of 
all  the  teeth,  the  posterior  or  palatine  surfaces  of  the  lateral  in- 
cisors; and,  in  short,  wherever  an  imperfection  of  the  enamel 
exists. 

The  enamel  is  much  harder  than  the  dentine,  and  is  by  far 
less  easily  acted  on  by  the  causes  that  produce'  caries.  It  is 
sometimes,  however,   the  first  to  be  attacked,  and   when  this 


i 


CARIES    OF    THE    TEETH,  235 

happens,  the  disease  develops  itself  more  frequently  on  the 
labial,  or  buccal  surface  near  the  gum,  than  in  any  other  local- 
ity; often  commencing  at  a  single  point,  and  at  other  times  at  a 
number  of  points.  When  the  enamel  is  first  attacked,  it  is 
usually  called  erosion ;  but  as  this  tissue  does  not  contain  so 
much  animal  matter  as  the  subjacent  dentine,  the  diseased  part 
is  often  washed  away  by  the  saliva  of  the  mouth ;  while  in  the 
dentinal  part  of  the  tooth,  it,  in  most  instances,  remains,  and 
may  be  removed  in  distinct  laminae,  after  the  earthy  salts  have 
been  decomposed. 

In  very  hard  teeth,  the  decayed  part  is  of  a  firmer  consistence, 
and  of  a  darker  color,  than  in  soft  teeth.  Sometimes  it  is  black ; 
at  other  times  of  a  dark  or  light  brown ;  and  at  other  times  again, 
it  is  nearly  white.  As  a  general  rule,  the  softer  the  tooth,  the 
lighter,  softer  and  more  humid  the  caries.  The  color  of  the 
decayed  part,  however,  may  be,  and  doubtless  is,  in  some  cases, 
influenced  by  other  circumstances;  perhaps  by  some  peculiar 
modification  of  the  agents  concerned  in  the  production  of  the 
disease. 

The  disease,  then,  not  being  the  result  of  any  vital  action, 
the  applicability  of  the  term  caries  may  be  questioned;  but,  as 
it  has  been  very  generally  sanctioned,  and  as  we  know  of  no 
better  name,  we  shall  continue  its  use.  Mr.  Bell  has  substituted 
the  term  gangrene,  under  the  belief  that  it  conveys  a  more  cor- 
rect idea  of  the  true  nature  of  the  afi'ection.  The  applicability 
of  a  term,  almost  synonymous  with  this,  is  also  suggested  by  Mr. 
Hunter:  in  speaking  of  the  afi'ection,  he  says,  that  it  "appears 
to  deserve  the  name  of  mortification."  Mr.  Fox  speaks  of  the 
decay  of  the  teeth,  as  a  disorder  which  terminates  in  mortifica- 
tion; but  he  designates  it  by  the  name  of  caries.  We  prefer 
this  term,  inasmuch  as  that  of  gangrene  or  mortification  may  be 
applied  to  another  condition  of  the  teeth — necrosis,  with  as  much 
propriety  as  to  the  one  now  under  consideration.  Moreover,  the 
term  gangrene,  or  mortification,  is  commonly  used  to  signify  the 
death  of  a  soft  part,  and  not  a  diseased  condition  of  bony  tissue. 
Surgical  writers  usually  regard  gangrene  in  soft  tissues  as  ana- 
logous to  necrosis  in  osseous  tissues ;  and  ulceration  in  the  first 
analogous  to  caries  in  the  last.  But  necrosis  and  caries  in  the 
teeth  differ  in  causes,  symptoms,  sequelae  and  treatment,  from 


236  CARIES    OF   THE   TEETH. 

affections  of  the  same  name  in  other  bones,  in  consequence  of 
the  great  difference  in  their  structure,  function  and  mode  of 
connection  with  the  adjacent  tissues. 

Commencing  externally  beneath  the  enamel,  the  disease  pro- 
ceeds, as  before  stated,  towards  the  centre  of  the  tooth,  destroying 
layer  after  layer,  until  it  reaches  the  lining  membrane,  leaving 
each  outer  stratum  softer,  and  of  a  darker  color  than  the  sub- 
jacent one. 

The  terms,  deep  seated^  superficial^  external  and  internal^ 
simple  and  complicated,  have  been  applied  to  the  disease.  These 
distinctions  are  unnecessary,  since  they  only  designate  different 
stages  of  the  same  affection.  By  complicated  decay,  is  meant 
caries  which  has  penetrated  to  the  pulp-cavity  of  the  tooth, 
accompanied  by  inflammation  and  suppuration  of  the  lining 
membrane,  and  the  death  of  the  organ.  The  lining  membrane, 
however,  is  not  always  inflamed  by  exposure,  nor  is  inflammation 
invariably  followed  by  suppuration. 

Equally  unnecessary  is  the  classification  adopted  by  M.  Duval, 
to  designate  differences  of  color  and  consistence  in  the  decayed 
part.  He  enumerates  seven  varieties  or  species,  as  follows: 
calcareous,  peeling,  perforating,  black,  deruptive,  stationary, 
and  wasting. 

The  first,  he  employs  to  denote  an  affection  of  the  teeth  cha- 
racterized by  the  appearance  of  a  white  opaque  spot  on  the 
enamel,  whereby  it  is  rendered  brittle,  and  which  often  causes 
it  to  break.  The  second,  if  not  identical  with,  is  at  least  ana- 
logous to,  the  first,  except  in  the  different  color  of  the  enamel. 
The  third  is  caused  by  a  defect  in  almost  every  part  of  the 
enamel  covering  the  crowns  of  the  teeth;  it  attacks  the  molars 
and  sometimes  the  bicuspids,  at  a  number  of  points  simulta- 
neously, causing  speedy  destruction.  The  fourth,  he  describes 
as  not  occurring  until  from  the  fifteenth  to  the  thirtieth  year, 
and  as  being  principally  confined  to  persons  of  consumptive  habit, 
and  those  disposed  to  rachitis.  The  color  of  the  decayed  part  of 
a  tooth  in  individuals  having  such  morbid  proclivity,  is  sometimes 
black,  but  more  frequently  white.  Black  caries,  as  it  is  called, 
is  oftener  met  with  in  the  teeth  of  persons  of  good  constitution, 
and  in  hard  rather  than  soft  teeth. 

The  fifth  species,  or  deruptive,  he  represents  as  that  which, 


DIFFERENCES   IN    LIABILITY    OF    TEETH    TO    DECAY.         237 

in  persons  of  consumptive  habit,  attacks  the  front  teeth  near 
their  necks,  extending  downward  toward  their  roots,  and 
forming  a  brownish  semicircular  groove.  The  sixth  is  that 
description,  which,  after  having  penetrated  a  certain  distance 
into  the  substance  of  the  tooth,  becomes  stationary.  The  seventh, 
and  last  species,  is  characterized  by  the  gradual  wasting  of  the 
grinding  surfaces  of  the  molars,  dipping  down  in  some  places  to 
a  considerable  depth,  and  leaving  a  smooth  polished  surface  of  a 
brown  or  yellowish  color. 

Finally,  the  roots  of  the  teeth  frequently  remain  firm  in  their 
sockets  for  years  after  the  crowns  and  necks  have  been  destroyed, 
showing  that  they  are  less  liable  to  decay  than  the  crowns ;  but 
nature,  after  the  destruction  of  the  last,  as  if  conscious  that  the 
former  are  of  no  further  use,  exerts  herself  to  expel  them  from 
the  system,  which  is  effected  by  the  gradual  wasting  and  filling 
up  of  their  sockets.  After  this  operation  of  the  economy  has 
been  accomplished,  they  are  frequently  retained  in  the  mouth 
for  months,  and  even  for  years,  by  their  periosteal  connection 
with  the  gums.  This  effort  of  nature  is  confined  more  to  the 
back  than  to  the  front  teeth;  it  often  happens  that  the  last 
remain,  after  the  destruction  of  their  crowns,  for  many  years, 
and  sometimes  without  much  apparent  injury  to  the  parts  within 
which  they  are  contained. 


DIFFERENCES   IN   THE   LIABILITY  OF  DIFFERENT  TEETH  TO 

DECAY. 

Having  explained  at  some  length,  in  a  preceding  part  of  this 
work,  the  manner  in  which  the  physical  condition  of  the  teeth  is 
influenced,  it  will  not  now  be  necessary  to  dwell  upon  this  portion 
of  the  subject.  It  will  only  be  requisite  to  state,  therefore,  that 
teeth  which  are  well  formed,  well  arranged,  and  of  a  firm  texture, 
seldom  decay,  and  when  they  are  attacked,  the  progress  of  the 
disease  is  not  rapid;  whereas,  those  that  are  imperfect  in  their 
formation,  and  of  a  soft  texture,  are  more  susceptible  to  the 
action  of  the  causes  which  produce  it ;  and  when  assailed,  if  the 
progress  of  the  affection  is  not  arrested  by  art,  they  usually  fall 
speedy  victims  to  its  ravages.  Just  in  proportion  as  the  dentinal 
structure  of  the  teeth  is  hard  or  soft,  the  shape  of  the  organs 


238         DIFFERENCES    IN    LIABILITY    OF   TEETH    TO    DECAY. 

perfect  or  imperfect,  their  arrangement  regular  or  irregular,  is 
their  liability  to  caries  diminished  or  increased. 

The  density,  shape  and  arrangement  of  the  teeth  are  in- 
fluenced by  the  state  of  the  general  health,  and  that  of  the 
mouth,  at  the  time  of  their  dentinification.  If,  at  this  period, 
all  the  functions  of  the  body  are  healthily  performed,  these 
organs  will  be  compact  in  their  structure,  perfect  in  their  shape, 
and  usually  regular  in  their  arrangement.  That  the  teeth  should 
be  thus  influenced  Avill  not  appear  strange,  when  we  consider,  as 
Richerand  remarks,  "  that  there  exists  amongst  all  the  parts  of 
the  living  body  intimate  relations,  all  of  which  correspond  to 
each  other,  and  carry  on  a  reciprocal  intercourse  of  sensations 
and  aff"ections.  Hence,  if  there  is  a  morbid  action  in  one  part, 
other  parts  sympathize  with  it,  rallying,  as  if  sensible  of  the 
mutual  dependence  existing  between  them,  all  their  energies  to 
rescue  their  neighbor  from  the  power  of  disease." 

Increased  action  in  one  portion  of  the  system,  is  generally- 
followed  by   diminished   action    in   some   other   part;    thus   for 
example,    gastritis   may  be   produced   by    constipation  of  the 
bowels :  puerperal  fever,  by  diminished  action  in  the  heart  with  ■ 
an  increased  action  in  the  uterus :  etc.     Hence,  we  may  con- 
clude, that  if  the  body,  at  an  early  age,  be  morbidly  excited,^ 
its  functions  will  be  languidly  performed — the  process  of  assimi-J 
lation  checked — the  regular  and  healthy  supply  of  earthy  mattet 
in  the   bones   interrupted  —  and,    consequently,   that  the  teetl 
which  are  then  formed  will  be  defective.     Other  parts  of  thej 
body,  in  Avhich  constant  changes  are  going  on,  if  thus  affected  at 
these    early    periods,   may   afterwards    recover    their    healthful 
vigor ;  but  if  the  teeth  are  badly  formed,  they  must  ever,  because 
of  their  low  degree  of  vascularity,  continue  so;  hence  they  will 
be  more  liable  to  decay  than  when  dentinified  under  other  and 
more  favorable  circumstances. 

Capillary  blood-vessels  form  a  large  part  of  every  organ,  the 
characteristic  tissue  of  each  being  strictly  extra-vascular  (lite- 
rally, outside  of  the  vessels).  Where  the  blood-vessels  are  most 
abundant,  as  in  the  nervous  and  muscular  structures,  growth 
and  change  take  place  rapidly  and  constantly;  since  almost  every 
particle  of  the  extra-vascular  or  interstitial  tissue  is  in  contact 
with  the  circulating  fluid,  the  function  of  which  is  to  supply  ma- 


DIFFERENCES    IN    LIABILITY    OF    TEETH    TO    DECAY.         239 

terial  for  growth  and  carry  oflF  waste  matter.  Hence  such  or- 
gans have  great  recuperative  power,  and  are  modified  by  the 
varying  conditions  of  the  body.  But  the  dentine  and  enamel  of 
the  teeth  are  vascular  only  during  the  period  of  development. 
These  structures,  once  formed,  pass  beyond  the  reach  of  the  ca- 
pillaries, except  the  layer  of  dentine  in  contact  with  the  dental 
pulp.  Hence,  the  dental  pulp  may  deposit  new  bone  as  a  bar- 
rier against  caries;  but  the  carious  dentine  itself  is  incapable  of 
self-restoration. 

"That  the  teeth  acquire  this  disposition,"  says  Mr.  Fox,  "to 
decay,  from  some  want  of  healthy'action  during  their  formation, 
seems  to  be  proved  by  the  common  observation,  that  they  become 
decayed  in  pairs ;  that  is,  those  which  are  formed  at  the  same 
time,  being  in  a  similar  state  of  imperfection,  have  not  the  power 
to  resist  the  causes  of  the  disease,  and  therefore,  at  nearly  about 
the  same  period  of  time  exhibit  signs  of  decay;  while  those 
which  have  been  formed  at  another  time,  when  a  more  healthy 
action  has  existed,  have  remained  perfectly  sound  to  the  end  of 
life." 

Most  writers  are  of  opinion,  that  the  powder  of  the  teeth  to 
resist  the  various  causes  of  decay  is  sometimes  weakened  by  a 
change  brought  about  in  their  physical  condition  through  the 
agency  of  certain  remote  causes,  such  as,  the  profuse  administra- 
tion of  mercury,  the  existence  of  fevers,  and  all  severe  constitu- 
tional disorders. 

Mr.  Fox  says :  "  That  he  has  had  occasion  to  observe,  that 
great  changes  take  place  in  the  economy  of  the  teeth  in  conse- 
quence of  continued  fever;  and  that  the  decay  of  the  teeth  is 
often  the  consequence  of  certain  states  of  the  constitution." 

Mr.  Bell  remarks:  "  That  amongst  the  remote  causes,  (of  de- 
cay,) are  those  which  produce  a  deleterious  change  in  the  consti- 
tution of  the  teeth,  subsequent  to  their  formation ;  one  of  the 
most  extensive,  in  its  effects,  is  the  use  of  mercury.  To  the 
profuse  administration  of  this  remedy  in  tropical  diseases  we 
may,  we  think,  in  a  great  measure,  attribute  the  injury  which  a 
residence  in  hot  climates  so  frequently  inflicts  on  the  teeth." 

Severe  constitutional  disorders,  and  the  administration  of  cer- 
tain kinds  of  medicine,  do  not,  as  Messrs.  Fox  and  Bell  suppose, 
act  directly  on  the  teeth,  by  altering  their  physical  condition 


240         DIFFERENCES   IN   LIABILITY   OF   TEETH    TO    DECAY. 

and  thus  rendering  them  more  susceptible  to  the  action  of  corro- 
sive agents ;  but  they  are  indirectly  affected  in  proportion  as  the 
secretions  of  the  mouth  are  vitiated  and  their  corrosive  proper- 
ties increased. 

The  following  considerations  establish,  to  our  mind,  the  truth 
of  what  we  have  just  stated.  Artificial  teeth  of  bone  or  ivory, 
which  can  undergo  no  such  changes  as  those  mentioned  by  Mr. 
Bell,  decay  more  rapidly  after  the  profuse  administration  of  any 
medicine,  or  during  the  existence  of  any  disease  that  tends  to 
vitiate  the  secretions  of  the  mouth,  than  at  other  times.  Fur- 
thermore, teeth  of  so  dense  a  texture,  as  to  be  capable  of  resist- 
ing the  action  of  the  acidulated  buccal  fluids  are  not  affected  by 
constitutional  disease;  yet  they  are  just  as  liable  as  those  of  a 
spongy  texture,  to  any  structural  disease  communicated  from  the 
general  system. 

The  following  is  the  result  of  our  own  observations:  The  gums 
and  alveolar  processes  are  sometimes  destroyed  by  the  use  of 
mercury,  so  that  all  the  teeth  loosen  and  drop  out,  without  being 
affected  by  caries.  The  teeth  of  persons,  in  wdiom  a  mercurial 
diathesis  has  been  for  a  long  time  kept  up,  or  who  have  been  for 
years  suffering  from  dyspepsia,  phthisis,  fevers,  or  other  severe 
constitutional  disorders,  often  continue  perfectly  sound ;  while 
other  teeth,  under  similar  circumstances,  frequently  decay.  Now, 
all  this  goes  to  prove,  not  that  changes  are  effected  in  the  struc- 
tural condition  of  the  teeth,  whereby  their  predisposition  to  decay 
is  increased ;  but  that  there  are  differences  in  the  capabilities  of 
different  teeth  to  resist  the  action  of  the  secretions  of  the  mouth, 
made  acrid  by  the  affections  just  enumerated. 

The  author  is  well  aware  that  he  differs  from  some  writers  on 
this  point,  as  well  as  from  received  popular  opinion.  The  views 
which  he  has  here  presented,  are  not  the  result  of  mere  closet 
reflections,  but  of  long  and  attentive  observation.  He  has  noted 
the  effects  of  mercury,  and  of  other  medicines,  as  well  as  of 
constitutional  diseases  of  the  severest  and  most  protracted 
kinds,  and  he  has  always  observed,  that — occurring  after  the 
development  of  the  teeth — it  was  only  as  they  impaired  the 
healthy  qualities  of  the  fluids  of  the  mouth,  that  they  affected 
these  organs.  In  fact,  their  density,  their  exposed'  situation, 
their  functions,  all  would  seem  to  indicate,  that  such  changes  as 


DIFFERENCES    IN    LIABILITY    OF   TEETH    TO    DECAY.         241 

take  place  in  other  parts  of  the  body,  are  not  only  unnecessary, 
but  many  of  them  are  impossible,  and  designedly  so.  that  they 
may  more  fully  answer  their  purpose. 

Dr.  Good  says:  "That  caries  of  the  teeth  does  not  appear  to 
be  a  disease  of  any  particular  age  or  temperament,  or  state  of 
health."  It  is  true  it  is  not  a  disease  of  any  particular  state  of 
health,  farther  than  that  certain  constitutional  affections  exert  a 
deleterious  influence  upon  the  secretions  of  the  mouth,  and  thus 
become  indirect  causes  of  decay  of  these  organs.  That  it  is  not 
a  disease  of  any  particular  age,  seems  to  contradict  common  ex- 
perience, for  it  comparatively  seldom  happens  that  caries  appears 
after  the  age  of  forty.  The  reason  of  which  is  obvious.  Teeth 
of  a  loose  texture,  or  otherwise  imperfect,  cannot  resist  the  ac- 
tion of  the  causes  of  decay,  to  which  all  teeth  are,  up  to  this 
period  of  life,  more  or  less  exposed ;  while  those  which  from 
their  greater  density  remain  unaffected  thus  long,  are  generally 
enabled,  by  the  increased  solidity  they  gradually  acquire,  to  re- 
sist them  through  life.  Teeth  sometimes,  though  rarely,  decay 
at  fifty,  or  even  at  a  later  period ;  but  caries  of  the  teeth,  gene- 
rally, may  be  said  to  be  confined  to  youth  and  middle  age. 

The  formation,  arrangement  and  physical  condition  of  the 
teeth  are  sometimes  influenced  by  hereditary  diathesis,  affecting 
the  parts  concerned  in  their  production,  or  the  general  system. 
That  a  morbid  condition  of  the  system,  on  the  part  of  either 
parent,  often  predisposes  their  progeny  to  like  affections,  is  an 
axiom  fully  recognized  in  pathology,  and  a  fact  of  which  we 
have  many  fearful,  proofs. 

Mr.  Bell,  in  treating  of  what  he  calls  the  hereditary  predis- 
position of  the  teeth  to  decay,  remarks:  "That  it  often  happens 
that  this  tendency  exists  in  either  the  whole  or  a  great  part  of  a 
family  of  children,  where  one  of  the  parents  had  been  similarly 
affected ;  and  this  is  true  to  so  great  an  extent,  that  we  have 
commonly  seen  the  same  tooth,  and  even  the  same  part  of  a 
tooth,  affected  in  several  individuals  of  the  family,  and  at  about 
the  same  age.  In  other  instances,  where  there  are  many  chil- 
dren, amongst  whom  there  exists  a  distinct  division  into  two  por- 
tions, some  resembling  the  father,  and  some  the  mother,  in  fea- 
tures and  constitution,  we  observe  corresponding  differences  in 
the  teeth,  both  as  it  regards  their  form  and  texture,  and  their 
tendency  to  decay." 


242  CAUSES    OF    CARIES. 

That  there  is  an  hereditary  tendency  in  the  teeth  to  decay, 
cannot,  we  think,  be  denied.  But  we  believe  it  to  be  the  result 
of  the  transmission  of  a  similarity  of  action  in  the  parts  con- 
cerned in  the  production  of  these  organs ;  so  that  the  teeth  of 
thq  child  are,  in  form  and  structure,  like  those  of  the  parent 
whom  it  most  resembles,  and  from  whom  it  has  inherited  the  dia- 
thesis. The  teeth  of  the  child,  if  shaped  like  those  of  the  parent, 
possessing  a  like  degree  of  density,  and  similarly  arranged,  are 
equally  liable  to  disease;  when  exposed  to  the  action  of  the 
same  causes  they  are  affected  in  like  manner,  and,  usually,  at 
about  the  same  period  of  life.  Such  being  the  fact,  is  it  un- 
reasonable to  conclude,  that  judicious  early  attention  may  so  in- 
fluence the  formation  and  arrangement  of  the  teeth,  that  their 
liability  to  disease  may  be  diminished  ?  Whilst  denying  the  di- 
rect action  of  medicine  and  sickness  upon  the  dental  tissues, 
except  through  the  agency  of  the  buccal  secretions,  we  admit 
their  powerful  influence ;  first,  through  hereditary  transmission  of 
an  impaired  constitution ;  secondly,  by  their  action  upon  the  pro- 
cess of  development,  if  given  while  the  teeth  are  being  formed. 
It  is,  then,  to  the  differences  in  the  physical  condition  and  man- 
ner of  arrangement  of  these  organs, — whether  in  different  indi- 
viduals  or  in  the  same  mouth, — that  the  differences  in  their  lia- 
bility to  decay  is  attributable. 

CAUSES  OF  CARIES. 

Caries  of  the  teeth  has  been  attributed  to  a  great  variety  of 
causes.  To  notice,  in  detail,  the  various  opinions  advanced  by 
American,  English,  French  and  German  writers  upon  this  sub- 
ject, would  be  inconsistent  with  the  plan  of  an  elementary  trea- 
tise like  this,  and  unprofitable  to  the  reader  ;  we  shall,  therefore, 
give  simply  a  brief  exposition  of  the  views  of  a  few  of  the  most 
prominent  writers.  If,  in  doing  this,  we  shall  have  occasion  to 
differ  from  any,  we  trust  we  shall  be  able  to  give  satisfactory 
reasons  for  so  doing. 

Fauchard,  Auzebe,  Bourdet,  Lecluse,  Jourdain,  and  most  of 
the  French  writers  of  the  eighteenth  century  on  the  diseases  of 
the  teeth,  as  well  as  nearly  all  of  the  more  modern  French 
authors,  though  their  views  with  regard  to  the  causes  of  dental 


CAUSES    OF   CARIES.  243 

caries  are  exceedingly  vague  and  confused,  express  the  belief 
that  the  disease  is,  for  the  most  part,  the  result  of  the  action  of 
chemical  agents  ;  such,  for  example,  as  vitiated  saliva,  the  pu- 
trescent remains  of  particles  of  food  lodged  between  the  teeth, 
or  in  their  interstices,  acids,  and  a  corrupted  state  of  the  fluids 
conveyed  to  these  organs  for  their  nourishment.  They  also 
mention  certain  states  of  the  general  health,  mechanical  injuries, 
sudden  transitions  of  temperature,  etc.,  as  conducing  to  the  dis- 
ease. A  similar  explanation,  too,  of  the  cause  is  given  by  Sal- 
mon, the  author  of  a  Compendium  of  Surgery,  published  in 
London,  in  1644.  The  foregoing  is  a  general  summary  of  the 
vicAvs  entertained  by  most  of  the  older  writers  with  regard  to  the 
causes  of  this  disease.  If  they  are  not  strictly  correct,  we  think 
we  shall  presently  be  able  to  show  that  they  are  not  altogether 
erroneous. 

In  the  English  school  of  dental  surgery,  since  the  time  of  the 
publication  of  Mr.  Fox's  celebrated  treatise  on  the  Natural 
History  and  Diseases  of  the  Teeth,  and  until  quite  recently,  in- 
flammation of  the  dentine  has  been  regarded  as  the  proximate  or 
immediate  cause  of  the  disease.  Having  discovered  an  identity 
of  structure  between  the  teeth  and  the  bones  of  the  body,  this 
author  immediately  concluded  that  the  diseases  of  the  one  were 
identical  with  those  of  the  other.  This  inference,  it  must  be 
confessed,  to  one  who  has  not  made  the  diseases  of  the  former  a 
subject  of  close  and  critical  investigation,  would  seem  to  be  ir- 
resistible. But  it  is  none  the  less  incorrect,  so  far,  at  least,  as 
most  of  the  diseases  of  the  teeth  are  concerned.  By  instituting 
a  comparison  between  caries  of  the  teeth  and  that  of  bone,  it 
will  at  once  be  perceived  that  there  is  not  the  slightest  analogy 
between  the  disease,  as  it  occurs  in  the  one,  and  as  it  shows  it- 
self in  the  other.  In  the  former,  it  consists  simply  in  a  decom- 
position of  the  earthy  salts  of  the  organs,  whereas,  in  the  latter, 
it  is  analogous  to  ulceration  in  soft  parts,  constantly  discharges 
purulent  matter,  and  often  throws  out  fungous  granulations. 
These  phenomena,  which  dental  caries  never  presents,  establish 
a  wide  diff"erence  of  character  between  it  and  the  disease  as  oc- 
curring in  the  true  osseous  structures  of  the  body. 

But  the  promulgation  of  the  doctrine  of  the  vascularity  of  the 
teeth,  not  only  led  to  the  belief  that  caries  of  these  organs  was 


244  CAUSES    OF    CARIES. 

identical  -with  caries  of  bone ;  but  it  soon  gave  rise  to  the  sup- 
position, that,  inasmuch  as  inflammation  Avas  the  cause  which 
determined  it  in  the  latter,  it  also  produced  it  in  the  former.* 
Amongr  the  ablest  advocates  of  this  theory  is  Mr.  Thomas  Bell : 
but  notwithstanding  the  support  which  it  has  received  from  his 
pen,  it  is  opposed  by  facts  which  prove  it,  most  conclusively,  to 
be  erroneous. 

If  inflammation  of  the  dentinal  structure  of  the  teeth  were 
the  cause  of  caries,  the  disease  would  be  as  likely  to  develop  it- 
self in  one  part  of  a  tooth  as  another.  The  root,  the  interior  of 
the  crown  between  the  pulp-cavity  and  the  enamel,  would  as 
frequently  be  the  part  first  attacked  as  the  external  surface. 
Now  what  are  the  facts  in  relation  to  this  matter  ?  Does  caries 
ever  commence  on  the  root  of  a  tooth,  or  between  the  pulp-cavity 
and  the  periphery  of  the  dentine  ?     Most  assuredly  not. 

Again,  among  the  causes  which  would  be  most  likely  to  excite 
inflammation  in  these  organs,  are  many  of  the  operations  per- 
formed for  arresting  the  progress  of  the  disease.  For  example, 
it  is  well  known  that  filing  and  plugging,  two  of  the  most  valu- 
able operations  in  dental  surgery,  augment,  for  a  time  at  least, 
the  sensibility  of  the  teeth,  and  increase  their  susceptibility  to 
the  action  of  heat  and  cold — agents  regarded  as  among  the  most 
frequent  and  powerful  exciting  causes  of  inflammation.  Now,  if 
dental  caries  were  the  result  of  inflammation,  these  operations, 
instead  of  arresting  the  progress  of  the  disease,  would  cause  a 
recurrence  of  it,  and  hasten  the  destruction  of  those  teeth  upon 
which  they  had  been  performed. 

Inflammation  of  the  lining  membrane  of  a  tooth  may  end  in 
suppuration,  but  we  cannot  believe  that  inflammation  of  its  den- 
tinal structure  alone,  causes  a  decomposition  of  any  portion  of  its 
substance,  though  it  may  influence  the  susceptibility  of  the  tooth 
to  the  action  of  caries.  For  were  such  a  change  produced  by 
any  vital  action,  the  part  deprived  of  vitality  would  be  exfoliated, 

*  The  doctrine  of  the  vascularity  of  the  teeth,  as  maintained  by  Fox,  was  the  origin 
in  England  of  the  theory,  that  caries  of  these  organs  resulted  from  inflammation  of 
their  dentinal  structure ;  but  the  doctrine  had  been  advanced  at  a  much  earlier  i)erio'J 
in  France.  The  celebrated  French  surgeon,  Ambrose  Pare,  in  treating  on  tooth-ache, 
says,  "  These  organs,  after  the  manner  of  other  bones,  suffer  inflammation,  and 
quickly  suppurate,  become  rotten,"  etc.,  book  xvii,  chap,  xxv,  page"  387 ;  edition, 
1579. 


CAUSES    OF   CARIES.  245 

and  its  loss  repaired  by  the  formation  of  new  dentine,  which 
never  happens ;  hence,  we  are  led  to  conclude  that  the  vital 
powers  of  the  teeth  are  too  weak  to  set  up  an  action  capable  of 
effecting  the  decomposition,  exfoliation,  or  restoration  of  any 
portion  of  their  substance.  Were  their  living  powers  more 
active,  it  is  probable  their  diseases  would  be  more  analogous  to 
those  of  bone. 

If  inflammation  of  the  dentine,  then,  is  not  the  cause  of  the 
affection,  how  is  the  disease  produced  ?  This  question  can  only 
be  answered  in  one  way.  It  is  the  result  of  the  action  of  exter- 
nal chemical  agents.  This  explanation  of  the  cause  is  not  based 
upon  mere  hypothesis,  but  is  supported  by  facts  that  cannot  be 
successfully  controverted.  It  is  well  known,  that  the  fluids  of 
the  mouth,  especially  the  mucous,  when  in  a  vitiated  condition, 
are  capable  of  decomposing  the  enamel  of  such  teeth  as  are  not 
possessed  of  more  than  ordinary  density.  The  truth  of  this 
assertion  is  demonstrated  by  the  fact  that  dead  teeth,  and  the 
crowns  of  human  teeth,  and  those  of  animals,  when  employed  as 
substitutes  for  the  loss  of  the  natural  organs,  are  as  liable  to  de- 
cay as  living  teeth,  and  the  decayed  part  in  the  one,  exhibits 
nearly  the  same  characteristics  as  in  the  other.  The  same  is 
true,  too,  with  regard  to  all  artificial  teeth  constructed  from  bone 
of  any  sort,  or  ivory.  Now,  if  the  disease  was  dependent  upon 
any  vital  operation,  neither  dead  teeth  nor  such  dental  substi- 
tutes as  we  have  mentioned,  would  ever  decay.  But  inasmuch 
as  they  do,  is  it  not  reasonable  to  suppose  that  the  cause  which 
produces  it  in  the  one  case  is  capable  of  producing  it  in  the 
other  ? 

But  it  may  be  asked,  if  caries  be  produced  by  the  action  of 
external  corrosive  ao-ents,  how  is  it  that  the  disease  sometimes 
commences  within  the  structure  of  a  tooth,  and  makes  consider- 
able progress  there,  before  any  indications  of  its  existence  are 
observed  externally  ?  We  answer,  that  it  never  does  commence 
there;  its  attacks,  as  we  have  before  remarked,  are  always  upon 
the  external  surface ;  sometimes  upon  the  enamel,  but  most  fre- 
quently upon  the  dentine  beneath  the  indentations  in  the  grind- 
ing surfaces  of  the  bicuspids  and  molars,  and  in  the  approximal 
sides  of  the  teetii,  where  this  outer  covering  is  often  so  fractured 
by  the  pressure  of  the  organs  against  each  other,  that  the  secre- 


246  CAUSES    OF   CARIES. 

tions  of  the  mouth  find  ready  access  to  the  subjacent  dentine. 
Decay  may  be  gradually  going  on  here  for  months  or  years  with- 
out any  manifest  signs  of  its  existence  :  and  the  progress  of  the 
disease  in  these  places  has  led  many  to  suppose  that  it  had  its 
origin  from  within. 

A  thorough  investigation  of  this  subject  ought  to  convince 
any  one,  that  caries  always  commences  externally.  If  it  com- 
menced in  the  interior  or  within  the  dentinal  substance,  as  is 
asserted  by  some  English  writers,  "  the  sphere  of  usefulness," 
as  is  very  justly  remarked  by  Dr.  Fitch,  "  on  the  part  of  the 
snrgeon  dentist,  would  be,  to  say  the  least  of  it,  extremely 
limited.  For,  if  their  observations  (alluding  to  those  of  Hunter, 
Fox,  Koecker  and  other  European  writers)  are  true,  this  disease, 
in  its  commencement,  in  one-half  of  the  cases,  is  entirely  out  of 
the  reach  of  medical  aid."  Dr.  Fitch,  however,  believes  that  it 
does  sometimes  commence  within  the  substance  of  the  tooth. 

But  a  still  more  absurd  theory  in  regard  to  the  cause  of  the 
disease  is  advanced  by  Mr.  Charles  Bew.  He  attributes  it  to 
the  arrest  of  the  circulation  in  the  organs,  "  by  the  lateral  pres- 
sure of  the  teeth  against  each  other." 

The  exposure  of  the  teeth,  too,  to  sudden  changes  of  tempera- 
ture, as  from  heat  to  cold,  or  cold  to  heat,  has  been  regarded 
almost  from  time  immemorial  as  the  cause  of  their  decay;  but 
no  explanation  was  attempted  of  the  manner  in  which  these 
agents  produce  the  disease,  until  the  promulgation  of  the  doc- 
trine that  it  was  the  result  of  inflammation ;  they  were  then 
numbered  among  the  exciting  causes.  The  popular  belief  that 
cold  is  a  cause  of  dental  caries,  is  traced  back  to  Hippocrates, 
who,  in  mentioning  the  parts  of  the  body  injuriously  affected  by 
it,  includes  the  teeth.* 

M.  Ribe  endeavors  to  prove  tliat  hot  food  is  a  cause  of  caries, 
from  the  fact,  that  "  man  is  the  only  animal  accustomed  to  hot 
food,  and  almost  the  only  animal  affected  with  carious  teeth." 
Had  this  writer  instituted  a  comparison  between  the  teeth  of 
man  and  of  brutes,  and  between  the  solvent  agents  to  which  they 
are  respectively  exposed,  he  might,  perhaps,  have  traced  the 
decay  of  the  human  teeth  to  its  proper  cause. 

*  Frigiduiu  inimicum  ossibus,  dentibus,  nervis,  cerebro,  spinali  medullfe ;  calidum 
vero  utile.    Aph.  sec.  v. — par.  IS. 


CAUSES    OF    CARIES.  247 

*' The  Indians  of  North  America,"  says  M.  Tillreus,  "knew 
nothing  of  the  inconvenience  of  carious  teeth  and  debilitated 
stomachs,  until  after  the  introduction  of  tea  amongst  them." 
From  this,  one  might  suppose  that  tea  caused  the  teeth  to  decay, 
and  that  dyspepsia  was  mainly  attributable  to  its  use.  The 
decay  of  the  teeth  of  these  people,  since  the  introduction  of  tea 
amongst  them,  may,  however,  be  more  plausibly  accounted  for. 
The  susceptibility  of  these  organs  to  the  action  of  such  causes 
as  produce  the  disease,  have  been  greatly  increased  by  the  im- 
paired state  of  their  general  constitutional  health  occasioned  by 
the  use  of  spirituous  liquors,  and  the  luxuries  common  to  civil- 
ized life,  in  which  they  have  indulged. 

Particular  sorts  of  diet,  too,  such  for  example,  as  animal  food, 
are  said  to  exercise  an  unhealthy  influence  upon  the  teeth.  In 
proof  of  the  assertion,  it  is  stated,  that  Indian  nations,  who  live 
principally  upon  vegetables,  scarcely  ever  have  a  tooth  to  decay. 
But  the  same  may  be  said  of  those  nations  who  subsist  chiefly  on 
animal  diet,  and  who  enjoy  an  equal  degree  of  constitutional 
health.  Savage  and  barbarous  people  usually  have  better  teeth 
than  those  of  civilized  nations,  probably  for  the  reason  that  their 
systems  are  not  enervated  by  luxurious  living.  So  far  as  diet 
is  capable  of  afi'ecting  the  health  of  the  body,  it  may  be  con- 
sidered as  an  indirect  cause  of  caries  ;  for  the  health  of  the  child 
is  not  always  dependent  on  the  health  of  the  parent.  To  the 
absence  of  disease  in  the  general  system  during  childhood,  the 
period  when  the  teeth  of  second  dentition  are  being  formed,  the 
soundness  of  the  teeth  of  savages  may  be  ascribed. 

It  is  absurd  to  suppose  that  caries  of  the  teeth  is  attributable 
to  the  use  of  animal  food.  It  is  incapable,  even  in  a  putrid 
state,  of  exerting  any  hurtful  action  on  them.  The  fibres  of 
animal  matter  may  be  retained  between  the  teeth  longer  than 
particles  of  vegetable  substance,  and  by  retaining  the  secretions 
of  the  mouth  until  they  become  vitiated,  contribute  indirectly  to 
caries. 

Those  parts  of  the  teeth  which  are  covered  with  thick  smooth 
enamel,  are  rarely  the  first  to  be  attacked  by  caries.  But  the 
chemical  agents  concerned  in  the  production  of  the  disease  may 
find  access  to  the  dentine  through  a  fracture  or  imperfection  of 
the  enamel  scarcely  perceptible  to  the  naked  eye,  and  hence,  the 


248  CAUSES    OF    CARIES. 

disease  is  sometimes  developed  in  a  part  not  usually  attacked 
by  it. 

Mr.  Tomes  believes  that  caries  of  a  tooth  is  always  preceded 
by  loss  of  vitality  in  the  affected  part,  and  that  it  is  not  until 
this  takes  place,  that  the  chemical  agents,  upon  the  action  of 
which  the  structural  alteration  is  produced,  are  capable  of  affect- 
ing the  solid  tissues  of  these  organs.  But  that  this  opinion  is 
erroneous  is  proven  by  the  fact,  that  the  animal  frame-work  of 
the  affected  part,  after  the  complete  decomposition  of  the  earthy 
salts,  is  often  so  exceedingly  sensitive,  that  the  slightest  touch 
of  an  instrument  is  productive  of  severe  pain,  thus  demonstrating 
conclusively  the  existence  of  remaining  vitality.* 

The  opinion  of  Mr.  Lintott,  with  regard  to  the  manner  in  which 
caries  is  produced,  is  founded  upon  the  endosmotic  phenomena 
which  he  thinks  take  place  in  the  structure  of  a  tooth.  That 
endosmosis  may  take  place  in  the  outer  part  of  a  tooth  is  possible, 
and  if  so,  the  secretions  of  the  mouth,  if  at  all  acidulated,  would 
be  likely  to  decompose  the  calcareous  molecules  with  which  they 
are  brought  in  contact  during  their  imbibition.  But  whether 
such  action  takes  place  or  not,  the  structural  alteration,  beyond 
doubt,  is  produced  by  chemical  agents. 

The  existence  of  an  acid  in  the  mouth,  capable  of  decomposing 
the  teeth,  is  conclusively  proven  by  Dr.  S.  K.  Mitchell,  in  a  letter 
addressed  by  him  to  T.  C.  Hope,  M.  D.,  of  Edinburgh,  dated  Oc- 
tober 10.  1796.  The  fact  may  be  demonstrated  by  a  very  simple 
experiment,  which  consists  in  moistening  a  piece  of  litmus  paper 
with  the  buccal  fluids  obtained  from  between  the  teeth,  where 
they  have  been  retained  until  they  have  become  vitiated.  If  this 
be  done,  the  paper  will  be  turned  red.  If,  then,  these  fluids, 
when  in  a  vitiated  condition,  are  possessed  of  acid  properties, 
they  must  necessarily  exert  a  deleterious  action  upon  the  teeth, 
by  decomposing  and  breaking  down  their  calcareous  molecules, 
or.  in  otlier  words,  causing  their  decay. 

The  acid  detected  by  Dr.  Mitchell  was  the  septic,  (nitrous,) 
but  the  acetic,  lactic,  oxalic,  muriatic  and  uric  have  been  de- 
tected in  the  saliva,  in  certain  states  of  the  general  health. 
Donne,  who  has  analyzed  the  fluids  of  the  mouth  with  great 
care,  says,  "  The  saliva,  in  its  normal  state,  is  alkaline,  but  the 

*  See  Tomes'  Lectures  on  Dental  Physiology  and  Surgery. 


CAUSES    OP    CARIES.  249 

secretions  of  the  mucous  membrane  of  the  mouth  are  acid."*  It 
is  highly  probable,  therefore,  that  the  acids  which  have  been 
detected  in  the  first  of  these  fluids,  may  have  been  principally 
derived  from  the  latter.  Acidity  of  the  saliva  may,  however, 
occur  in  certain  morbid  conditions  of  the  general  system.  Donne 
says,  he  has  observed  it  in  patients  afi"ected  with  gastritis,  and 
in  children  with  aphthge.  It  is  to  the  action  of  these  acids  upon 
those  parts  of  the  teeth,  against  which  they  are  long  retained, 
that  caries  is  principally  attributable. 

The  doctrine  that  the  deca}^  of  the  teeth  is  the  result  of  the 
action  of  external  corrosive  agents,  was  first  distinctly  promul- 
gated to  the  dental  profession  of  the  United  States,  about  the 
year  1821,  by  Drs.  L.  S.  and  Eleazar  Parmly.  These  agents 
may  consist — of  menstrua,  formed  by  the  decomposition  of  acet- 
ous fermentation  of  the  remains  of  certain  aliments,  lodged  in 
the  interstices  of  the  teeth  ;  or  of  the  fluids  of  the  mouth,  especi- 
ally the  mucous,  in  a  A^tiated  or  acidulated  condition  ;  or  of  acids 
administered  during  sickness,  or  used  as  condiments.  According 
to  the  tables  of  elective  afiinity,  there  are  but  four  acids  which 
precede  the  phosphoric  in  their  affinity  for  lime  :  namely,  the 
oxalic,  sulphuric,  tartaric  and  succinic.  It  may  hence  be  argued, 
that  none  of  the  other  acids  are  capable  of  decomposing  the  teeth, 
or  of  injuring  them  in  any  other  way,  but  daily  observation 
proves  the  erroneousness  of  this  conclusion.  It  has  been  shown 
by  experiment  that  all  the  acids,  both  vegetable  and  mineral, 
act  more  or  less  readily  upon  these  organs. f   But  we  are  disposed 

*  Goiirs  de  Microscopic,  p.  209. 

I  The  following  experiments,  made  by  Dr.  A.  Westcott,  in  1843,  assisted  by  Mr. 
Dalrymple,  were  repeated  some  years  later,  before  the  class  of  the  Baltimore  Dental 
College : 

"1st.  Both  vegetable  and  mineral  acids  act  readily  upon  the  bone  and  enamel  of 
the  teelh. 

"2d.  Alkalies  do  not  act  upon  the  enamel  of  the  teeth;  the  caustic  potash  will 
readily  destroy  the  bone  by  uniting  with  its  animal  matter. 

".3d,  Salts  whose  acids  have  a  stronger  affinity  for  the  lime  of  the  tooth,  than  for 
the  basis  with  which  they  are  combined,  are  decomposed,  the  acids  acting  upon  the 
teeth. 

"4th.  Vegetable  substances  have  no  effect  upon  the  teeth  till  after  fermentation 
takes  place,  but  all  such  as  are  capable  of  acetic  fermentation,  act  readily  after  this 
acid  is  formed. 

'  5th.  Animal  substances,  even  while  in  a  state  of  coniincd  putrefaction,  act  very 
tardily,  if  at  all,  upon  either  the  bone  or  enamel.     On  examining  the  teeth  subjected 

17 


250  CAUSES    OF    CARIES. 

to  believe  that  caries  of  the  teeth  results  more  frequently  from 
the  action  of  some  acid  contained  in  the  mucous  fluids  of  the 
mouth,  than  from  that  of  acid  medicines  or  condiments,  or  even 
from  such  acids  as  may  be  generated  by  the  acetous  fermentation 
of  particles  of  certain  kinds  of  food  lodged  between  the  teeth. 
The  author  is  of  opinion,  therefore,  that  if  all  the  functional 
operations  of  the  body  were  always  healthily  performed,  caries 
of  the  teeth  would  seldom  occur ;  for,  in  this  case,  the  alkalinity 
of  the  saliva  would  be  sufficient  to  neutralize  the  acidity  of  the 
mucous  fluids  of  the  buccal  cavity,  as  well  as  any  other  acids 
generated  in  the  mouth. 

The  foregoing  theory  of  the  cause  of  dental  caries,  explains 
the  rationale  of  the  treatment  at  present  adopted  for  arresting 
its  progress.  By  the  removal  of  the  decomposed  part  and  filling 
the  cavity  with  an  indestructible  material,  the  contact  of  those 
agents  upon  the  chemical  action  of  which  the  disease  depends,  is 
prevented,  and  the  further  progress  of  the  decay  arrested. 

Among  the  indirect  causes  of  caries,  the  following  may  be 
enumerated :  depositions  of  tartar  upon  the  teeth ;  a  febrile  or 

to  such  influence,  the  twentieth  day  of  the  experiment,  no  visible  phenomena  were 
presented,  except  a  slight  deposit  upon  the  surface,  of  a  greenish  slimy  matter,  some- 
what resembling  the  green  tartar  often  found  upon  teeth  in  the  mouth. 

"  To  give  a  more  definite  idea  of  the  deleterious  agents  to  which  the  teeth  are  ex- 
posed, and  their  consequent  liability  to  be  afifeeted  by  them,  we  will  notice  the  effect 
produced  by  a  few  of  the  individual  substances,  which  are  more  or  less  liable  to  be 
brought  in  contact  with  the  teeth. 

"Acetic  and  citric  acids  so  corroded  the  enamel  in  forty-eight  hours,  that  much  of 
it  was  easily  removed  with  the  finger  nail. 

"  Acetic  acid,  or  common  vinegar,  is  not  only  in  common  use  as  a  condiment,  but  is 
formed  in  the  mouth  whenever  substances,  liable  to  fermentation,  are  suffered  to  remain 
about  the  teeth  for  any  considerable  length  of  time. 

"Citric  acid,  or  lemon  juice,  though  less  frequently  brought  in  contact  with  the 
teeth,  acts  upon  them  still  more  readily. 

*'  Malic  acid,  or  the  acid  of  apples,  in  its  concentrated  state,  also  acts  promptly  upon 
the  teeth. 

'•'Muriatic,  sulphuric  and  nitric  acids,  though  largely  diluted,  soon  decompose  the 
teeth — these  are  in  common  use  as  tonics. 

"  Sulphuric  and  nitric  ethers  have  a  similar  deleterious  effect,  as  also  spirits  of  nitre 
— these  are  common  diffusible  stimulants  in  sickness. 

'  Supcr-tartrate  of  potash  destroyed  the  enamel  very  readily.  This  article  is  fre- 
quently used  to  form  an  acidulated  beverage. 

"  Raisins  so  corroded  the  enamel  in  twentj'-four  hours,  that  its  surface  presented  the 
appearance  and  was  of  the  consistency  of  chalk. 

"  Sugar  had  no  effect  till  after  acetous  acid  was  formed,  but  then  the  effect  was  the 
same  as  from  this  acid  when  directly  applied." 


PREVENTION    OF    CARIES.  251 

irritable  state  of  the  body ;  a  mercurial  diathesis  of  the  general 
system ;  artificial  teeth  improperly  inserted,  or  made  of  bad 
materials  ;  roots  of  teeth  ;  irregularity  in  the  arrangement  of  the 
teeth ;  too  great  pressure  of  the  teeth  against  each  other — in 
short,  everything  that  is  productive  of  irritation  to  the  alveolo- 
dental  membrane,  or  to  the  gums. 

The  doctrine  here  advocated  is  one,  which,  we  confess,  we 
were  for  a  long  time  unwilling  to  believe,  because  it  was  opposed 
to  all  our  earlier  preconceived  notions  upon  the  subject;  but 
long  and  attentive  observation  has  forced  us  to  acknowledge  its 
truth. 

It  will  be  perceived,  from  the  foregoing  exposition  of  the  causes 
of  dental  caries,  that  three  distinct  theories  have  been  advanced 
upon  the  subject,  namely:  1.  The  vital,  as  advocated  by  Par^, 
Fox,  Bell,  and  some  others.  2.  The  chemical,  as  maintained  by 
nearly  all  French  authors,  by  Salmon,  Drs.  L.  S.  and  E.  Parmly, 
and  by  almost  all  late  writers.  3.  The  chemieo-vital,  of  Tomes. 
We  might  also  add  the  endosmotic  theory  of  Lintott,  which,  in 
fact,  is  nothing  more  than  an  explanation  of  the  supposed  man- 
ner in  which  chemical  agents  are  brought  into  more  direct  con- 
tact with  the  earthy  salts  of  a  tooth. 

PREVENTION  OF  CARIES. 

It  is  an  old  adage,  no  less  true  than  trite,  that  "an  ounce  of 
prevention  is  better  than  a  pound  of  cure,"  and  in  the  present 
instance  it  may  be  applied  with  its  full  force.  Were  more  atten- 
tion paid  to  the  practical  instruction  thus  conveyed,  many  of  the 
diseases  of  the  teeth  might  be  avoided.  Most  of  the  remarks 
that  might  be  made  on  this  subject  have  been  anticipated ;  con- 
sequently, it  will  only  be  necessary  to  observe,  that  if  the  teeth 
are  well  formed  and  well  arranged,  all  that  will  be  required,  is 
to  keep  them  clean ;  if  any  irregularity  occurs,  it  should  be 
remedied  by  the  means  before  described. 

For  cleansing  the  teeth,  the  regular  and  frequent  use  of  a 
brush  and  waxed  floss-silk  will,  in  most  cases,  be  sufficient.  The 
enamel  should  be  kept  free  from  all  stains  and  discolorations,  by 
the  employment,  if  necessary,  once  a  day,  of  a  dentrifice  ;  either 
of  the  following  may  be  used : 


i^; 

Prepared  chalk 

5iv. 

Powdered  orris  root 

!iv. 

Powdered  cinnamon 

3iv. 

Sup.  carb.  of  soda 

5ss. 

White  sugar 

!>• 

Oil  of  lemon 

gtt.  XV 

Oil  of  rose 

gtt.  ij. 

252  TREATMEXT    OF    CARIES. 

Prepared  chalk  |ij 

Powdered  orris  root     §ij. 
Pumice  stone  §j. 

Ingredients  in  both  prescriptions  to 
be  thoroughly  pulverized  and  well 
mixed. 

The  importance  of  keeping  the  teeth  clean  cannot  be  too 
strongly  impressed  upon  the  mind  of  every  individual.  Pi'oper 
attention  to  the  cleanliness  of  these  organs  contributes  more  to 
their  health  and  preservation  than  is  generally  supposed.  Against 
caries  it  is  a  most  powerful  prophylactic.  "Where  the  teeth," 
says  Dr.  L.  S.  Parmly,  "are  kept  literally  clean,  no  disease  will 
ever  be  perceptible.  Their  structure  will  equally  stand  the  sum- 
mer's heat  and  winter's  cold,  the  changes  of  climate,  the  varia- 
tion of  diet,  and  even  the  diseases  to  which  the  other  parts  of 
the  body  may  be  subject  from  constitutional  causes," 

The  configuration  and  arrangement  of  some  teeth  is  such, 
however,  as  to  preclude  the  possibility  of  keeping  them  clean; 
but  this  should  not  deter  any  one  from  using  the  proper  means, 
for  if  disease  is  not  wholly  prevented,  they  will,  at  least,  con- 
tribute very  greatly  to  the  preservation  of  the  organs. 

TREATMENT  OF  CARIES. 

Although  the  physical  condition  of  the  teeth  is  sometimes  such 
as  to  render  them  exceedingly  susceptible  to  the  attacks  of  caries, 
there  is  no  disease  to  which  the  body  is  liable,  that  can  be  treated 
with  a  more  certain  prospect  of  success  than  this.  If  taken  in 
time,  it  can  almost  always  be  arrested;  that  in  the  majority  of 
cases  it  is  not,  is  attributable  more  to  want  of  skill  on  the  part  of 
the  dentist,  than  to  the  incurable  nature  of  the  disease.  The 
treatment,  to  be  effectual,  must  be  thorough,  and  there  is  no 
branch  of  manual  medicine  that  requires  more  judgment,  or  a 
greater  amount  of  skill,  than  the  one  within  whose  province  the 
treatment  of  the  disease  under  consideration  comes. 

As  a  general  rule,  before  any  treatment  is  instituted  for  the 
purpose  of  arresting  its  progress,  the  gums  and  alveolo-dental 
periosteum  should  be  in,  at  least,  a  tolerably  healthy  condition ; 


1 


TREATMENT    OF    CARIES.  253 

for  if  they  are  inflamed,  or  ulcerated,  or  in  a  highly  irritable 
state  at  the  time,  the  most  skillfully  applied  remedies  may  prove 
unavailing.  If,  therefore,  these  structures  are  diseased,  such, 
treatment  as  may  be  necessary  to  their  restoration,  and  which 
will  hereafter  be  described,  should  first  be  had  recourse  to. 

The  treatment  for  arresting  the  progress  of  caries  consists  of 
two  operations — filing  and  filling.  The  first  is  for  superficial 
caries  on  the  lateral  or  approximal  surfaces  of  the  teeth,  and  as 
preparatory  to  the  other,  when  the  disease  is  situated  in  the  sides 
of  the  organs.  The  second  is  for  deep-seated  caries,  and  the 
manner  of  performing  each  will  be  described  in  the  two  follow- 
ing chapters. 


CHAPTER     SECOND. 
FILING  TEETH. 

There  is  no  operation  in  dental  surgery,  against  which  a 
stronger  or  more  universal  prejudice  prevails,  than  that  of  filing 
the  teeth;  yet,  when  judiciously  and  skillfully  performed,  there 
is  no  one  more  beneficial,  or  effectual  in  arresting  the  progress 
of  caries.  Thousands  of  teeth  are  every  year  rescued  from  its 
ravages,  and  preserved  through  life,  by  it.  But,  although  it  is 
productive  of  so  much  good,  it  is  also,  in  the  hands  of  ignorant 
and  unskillful  operators,  productive  of  incalculable  injury. 

With  regard  to  the  merits  of  this  wrongly-judged  and  much- 
abused  operation,  the  author's  views  are  so  fully  expressed  by 
the  late  Dr.  John  Harris,  in  a  paper  published  in  the  September 
No.  of  vol.  5,  of  the  American  Journal  of  Dental  Science,  that 
he  cannot  do  better  than  quote  his  remarks  upon  the  subject. 

He  says,  "  Filing  the  teeth  is  one  of  the  most  important  and 
valuable  resources  of  the  dental  art ;  it  is  one  that  has  stood  the 
test  of  experience,  and  is  of  such  acknowledged  utility,  as  to 
constitute  of  itself,  in  the  treatment  of  superficial  caries  on  the 
lateral  surfaces  of  the  teeth,  one  of  the  most  valuable  operations 
that  can  be  performed  on  these  organs.  And  even  after  caries, 
in  the  localities  just  mentioned,  has  progressed  so  far  as  to  ren- 
der its  removal  by  this  means  impracticable  or  improper,  the  use 
of  the  file,  in  most  cases,  is  still  necessary,  in  order  to  the  suc- 
cessful employment  of  other  remedial  agents.  But  in  either 
case,  a  failure  to  accomplish  the  object  for  which  it  is  used, 
would  only  be  equivalent  to  doing  nothing  at  all. 

"  The  use  of  the  file,  then,  may  very  justly  be  considered  a 
sine  qua  non,  for  the  removal  of  superficial  caries  from  the  sides 
of  the  teeth  which  come  in  contact  with  each  other,  as  can  be 
attested  by  thousands  of  living  witnesses ;  and  in  preparing  the 
way,  in  deep-seated  caries,  for  the  thorough  removal  of  the  dis- 
ease, and  filling,  successfully,  the  cavity  thus  formed. 


FILING    TEETH.  255 

"  In  a  paper  written  by  myself,  some  eleven  or  twelve  years 
ago,  upon  this  subject,  I  contended  that  filing  the  teeth  was  not 
necessarily  productive  of  caries,  and  my  subsequent  experience 
and  observations  have  only  tended  to  confirm  the  correctness  of 
the  opinion  which  I  then  advanced,  and  I  cherish  the  belief  that 
this  opinion  will  not,  at  this  time,  conflict  with  the  views  of  the 
more  enlightened  of  my  professional  brethren. 

"  But  when  reference  is  had  to  the  physical  peculiarities  of 
the  teeth,  it  will  at  once  be  perceived,  that  they  present  a  strange 
departure  from  the  laws  that  govern  and  control  all  other  parts 
of  the  body ;  and  these  organs,  when  diseased,  can  only  be  re- 
stored to  health  and  usefulness  by  art,  unaided  by  the  sanitary 
powers  of  nature.  Hence  it  is,  that  most  of  the  operations  upon 
them  will  not,  like  those  in  general  surgery,  admit  of  mediocrity 
in  their  performance. 

"  The  fact  that  the  crowns  of  the  teeth  are  covered  with 
enamel,  is  alone  sufficient  evidence  of  its  importance  and  utility 
in  shielding  and  protecting  the  bony  structure  which  it  envelops 
from  mechanical  and  morbid  influences  ;  so  that  it  would  seem 
that  its  removal  or  loss  Avould  necessarily  expose  the  organs  to 
certain  destruction.  But  we  have  satisfactory  evidence,  that 
teeth,  after  having  suffered  the  loss  of  large  portions  of  the 
enamel,  have  been  restored  to  health,  and  preserved  for  many 
years,  and  often  through  life. 

"  The  rapidity  with  which  caries  progresses  after  the  exposure 
of  the  bone  by  the  loss  of  the  enamel,  depends  upon  the  ph^^sical 
peculiarities  of  the  teeth,  and  upon  local  and  constitutional  in- 
fluences ;  hence  the  difficulty,  and  oftentimes  impossibility  of  ob- 
taining the  object  for  which  dental  operations  are  instituted, 
while  such  influences  are  suffered  to  exist.  If  special  regard  is 
not  had  to  the  curative  indications,  most,  if  not  all  the  opera- 
tions upon  the  teeth,  which  have  for  their  object  their  ultimate 
preservation,  are  sure,  to  a  greater  or  less  extent,  to  augment  all 
of  the  previously  existing  local  affections,  by  increasing  the  irri- 
tability of  the  parts,  and  by  rendering  them  more  susceptible  of 
being  acted  upon  both  by  local  and  constitutional  causes. 

"Without  indulging  in  further  prefatory  remarks,  I  shall  pro- 
ceed to  notice  more  particularly  the  subject  under  consideration. 


256  FILING    TEETH. 

And  I  would  here  observe,  that  an  experience  obtained  from 
twentj^-three  years'  constant  practice,  has  fully  convinced  me, 
not  only  of  the  propriety,  but  of  the  absolute  necessity  in  the 
treatment  of  caries  in  the  lateral  surfaces  of  the  teeth,  of  em- 
ploying the  file.  There  is  no- instrument  so  well  adapted  as  this 
for  the  removal  of  the  disease  when  situated  in  these  parts  of 
the  teeth,  especially  when  the  organs  are  in  close  proximity  with 
each  other ;  or  for  the  removal  of  rough  and  weakened  edges  of 
the  enamel  in  deep-seated  caries,  and  for  making  sufficient  space 
or  room  for  the  removal  of  the  diseased  parts  preparatory  to 
plugging. 

"  It  may  be  laid  doAvn  as  a  rule,  from  which  exceptions  should 
never  be  taken,  that  the  file  should  not  be  used,  while  the  teeth 
or  their  contiguous  parts  are  suffering  general  or  local,  acute  or 
chronic,  inflammation.  Therefore,  when  this  is  the  case,  the 
treatment  of  the  general  and  local  affections  should  precede  the 
operation  of  filing.  Upon  the  removal  of  all  the  acute  or  chronic 
diseases  of  the  mouth  greatly  depends  the  success  of  the  dentist 
in  the  treatment  of  aflfections  of  the  teeth,  calling  for  the  em- 
ployment of  the  file.  As  much  importance,  therefore,  is  to  be 
attached  to  an  enlightened  and  discriminating  judgment,  as  to 
tact  in  the  performance  of  the  operation. 

"In  fact  the  removal  of  all  local  causes  of  irritation — such  as 
dead  roots  of  teeth,  teeth  occasioning  alveolar  abscesses,  or  such 
as  exert  a  morbid  influence  upon  the  surrounding  parts,  and  all 
depositions  of  salivary  calculus  or  other  foreign  matter — should 
precede  all  other  operations  upon  these  organs. 

"  The  length  of  time  necessary  for  the  restoration  of  the  parts 
contiguous  to  the  teeth,  may  vary  from  a  few  days  or  weeks  to 
af<  many  months,  depending  upon  the  nature  and  extent  of  the 
disease,  the  general  health  of  the  patient,  and  the  constitutional 
as  well  as  local  treatment  to  which  they  are  subjected. 

"  In  assuming  the  position,  that  filing  the  teeth  does  not,  of 
necessity,  cause  them  to  decay,  it  is  by  no  means  to  be  inferred, 
that  the  operation  can,  in  all  cases,  and  under  all  circumstances, 
be  performed  with  advantage  or  even  impunity.  Its  eff'ects,  like 
those  of  most  other  operations  upon  the  teeth,  when  the  curative 
indications  are  disregarded,  or  not  properly  carried  out,  are 
most  injurious.     The  employment  of  the  file  at  an  improper  time, 


FILING    TEETH.  257 

and  in  an  improper  manner,  increases  the  liability  of  teeth  to 
decay ;  it  augments  the  irritability  of  all  the  parts  adjacent  to 
them,  and  consequently  their  susceptibility  of  being  acted  upon 
by  local  and  constitutional  causes. 

"The  principal,  and,  I  believe,  only  objection,  urged  against 
filing  the  teeth,  is  based  upon  the  erroneous  opinion,  that  the 
loss  of  any  part  of  the  enamel  of  these  organs  must  necessarily 
result  in  their  destruction.  But,  if  this  be  true,  why  is  it,  as  I 
have  on  another  occasion  asked,  that  the  negroes  of  Abyssinia 
have  such  sound  teeth  as  they  are  represented  to  have ;  since  it 
has  long  been  a  custom  with  them  to  file  all  their  front  teeth  to 
points,  so  as  to  make  them  resemble  the  teeth  of  a  saw  or  those  of 
carnivorous  animals  ?  Of  course,  large  'portions  of  the  enamel 
and  much  of  the  bony  structure,  must  be  removed  in  the  opera- 
tion, yet  we  are  credibly  informed  that  their  teeth  seldom  decay. 
The  same  may  be  said  of  the  Brahmins  of  India,  who,  from  re- 
mote ages,  have  been  in  the  habit  of  using  the  file ;  principally, 
I  believe,  for  separating  their  teeth,  yet  they  too  are  noted  for 
having  fine  teeth.  I  might  refer  to  the  people  of  other  coun- 
tries, with  whom  the  same  practice  has  long  had  an  existence, 
but  it  is  unnecessary  to  go  abroad  for  proof,  when  we  have  such 
an  abundance  of  it  at  home,  to  establish  the  propriety  and  abso- 
lute necessity  for  the  practice  I  am  now  advocating. 

''  With  the  people  just  referred  to,  it  is  evident  that  they  file, 
principally,  for  the  purpose  of  ornamenting  their  teeth ;  we  use* 
it  only  as  a  remedial  agent  in  the  treatment  of  disease.  The 
reason  why  their  teeth  are  not  so  subject  to  disease  as  are  those 
of  the  inhabitants  of  civilized  countries,  is  attributable  to  the 
difference  in  their  habits  of  life,  mode  of  living,  and  to  the  ab- 
sence of  the  causes  productive  of  the  various  diseases  peculiar  to 
civilization  and  refinement. 

"Notwithstanding  the  utility  and  value  of  the  operation,  filing 
the  teeth  may  be  regarded  as  a  predisposing  cause  of  caries.  If 
this  be  true,  it  may  be  asked,  why  file  at  all  ?  I  answer,  in  this 
country,  owing  to  the  prevalence  of  the  immediate  or  direct  cause 
of  caries,  the  operation  is  only  performed  as  remedial,  for  the 
purpose  of  removing  actual  disease  or  as  preparatory  to  plugging. 
It  does  not,  of  necessity,  follow,  that  caries  of  the  teeth,  after 
having  been  judiciously  removed  or  treated,  although  the  organs 


258  FiLixa  TEETH. 

be  predisposed  to  the  disease,  will  ever  again  occur.  The  gene- 
ral system  often  escapes  the  development  of  those  diseases  to 
which  it  is  predisposed  through  life  ;  so  also  do  the  teeth.  If 
the  operation  be  properly  performed,  and  the  filed  surfaces  kept 
thoroughly  clean,  a  recurrence  of  the  disease,  notwithstanding 
the  increased  predisposition  thus  induced,  will  never  take  place. 
The  immediate  cause  of  dental  caries  being  the  contact  of  corrosive 
agents  with  the  teeth,  the  necessity  for  this  precaution  is  obvious. 
The  bony  structure  of  these  organs  is  more  easily  acted  upon  by 
such  causes,  than  the  enamel ;  for  this  reason,  when  it  becomes 
necessary  to  expose  it  with  a  file,  for  the  removal  of  disease,  it 
should  be  done  in  such  a  way  as  to  admit  of  its  being  kept 
thoroughly  and  constantly  clean ;  so  that,  if  it  afterwards  be- 
comes carious,  it  will  be  owing  altogether  to  inattention  of  the 
patient.  In  view  of  this,  whenever  it  becomes  necessary  to  file 
the  teeth,  whether  for  the  complete  removal  of  caries,  or  as  only 
preparatory  to  plugging,  we  should  always  impress  upon  the 
patient  the  importance  of  cleansing  the  surfaces  thus  operated 
upon,  at  least  three  or  four  times  every  day.  The  future  pre- 
servation of  the  organs  will  depend  upon  the  constant  and 
regular  observance  of  this  precaution,  esj^ecially  when  they  are 
of  a  soft  or  chalky  texture,  for  they  are  then  far  more  easily  acted 
upon  by  decomposing  agents  than  when  hard. 

"  The  cases  requiring  the  use  of  the  file  vary  so  much,  that  it 
Vould  be  difficult  to  lay  down  precise  directions  with  regard  to 
the  extent  to  which  the  operation  should  be  carried.  This  must 
be  determined  by  the  judgment  of  the  operator.  The  design  of 
the  operation  may  be  defeated  either  by  filing  too  much  or  too 
little.  Either  extreme  should  be  avoided  ;  but  it  is  my  opinion, 
that  by  far  the  greater  number  of  unsuccessful  results  are  attri- 
butable, rather  to  the  too  moderate,  than  to  the  too  great  use  of 
this  instrument ;  especially,  where  the  circumstances  of  the  case 
have  nothing  to  do  in  determining  the  result. 

"  It  is  not  my  object  to  describe  the  manner  in  which  teeth 
should  be  filed,  but  merely  to  offer  a  few  general  remarks  on  the 
advantages  that  result  from  it  when  the  operation  is  judiciously 
performed ;  also  to  show  that  it  is  from  the  abuse  of  the  file,  in 
the  hands  of  the  ignorant  and  inexperienced  practitioner,  that 
its  merits  have  been  so  often  erroneously  estimated.     It  will  be 


FILING    TEETH.  259 

perceived,  from  the  foregoing  remarks,  that  its  utility  depends 
upon  carrying  out  all  the  curative  indications,  and  that  it  should 
never  be  resorted  to  except  in  the  absence  of  disease  in  the 
parts  with  which  these  organs  are  immediately  connected. 
Therefore,  to  estimate  the  merits  of  the  operation  correctly,  we 
should  know  all  the  circumstances  under  which  it  has  been  per- 
formed, the  competency  of  the  operator,  and  whether  he  was 
permitted  the  free  exercise  of  his  judgment.  The  dentist  is 
often  called  upon  to  render  his  services,  where,  from  the  timidity 
or  ignorance  of  his  patient,  he  is,  if  he  consents  to  operate  at 
all,  so  restricted  in  the  application  of  his  remedies,  that  little  if 
anything  more  than  temporary  relief  can  be  afforded.  And 
cases  may  occasionally  occur,  in  which,  from  unforeseen  circum- 
stances, even  after  the  most  skillful  management,  the  dentist 
may  be  disappointed  in  his  expectations,  and  fail  in  the  attain- 
ment of  the  object  for  which  his  services  were  solicited." 

It  is  scarcely  necessary  to  give  any  directions  with  regard  to 
the  manner  of  holding  the  file.  In  filing  the  front  teeth  and 
those  on  the  right  side  of  the  mouth,  the  operator  should  stand 
to  the  right  and  a  little  behind  the  patient,  in  order  to  steady 
the  head,  as  it  rests  against  the  back  of  the  operating  chair,  with 
his  left  arm  ;  while  with  the  fingers  of  the  left  hand  the  lips  are 
raised  and  the  teeth  properly  exposed  for  the  operation.  In 
filing  the  teeth  on  the  left  side  of  the  mouth  it  may  be  necessary 
for  the  operator  to  stand  upon  the  left  side  of  his  patient.  The 
file,  firmly  grasped  between  the  thumb  and  middle  finger  of  the 
right  hand,  with  the  end  of  the  forefinger  resting  upon  its  outer 
end,  should  be  moved  backward  and  forward  in  a  direct  line,  as 
any  deviation  from  this  would  immediately  snap  the  instrument. 
The  first  opening  between  the  teeth,  when  the  approximal  edges 
of  the  two  are  carious,  should  be  made  with  a  flat  file,  about  one- 
fourth  of  a  line  in  thickness,  cut  on  both  sides  and  both  edges ; 
this  done,  a  file  cut  on  one  side  and  both  edges  should  be  em- 
ployed for  the  completion  of  the  operation.  If  only  one  tooth 
is  decayed,  the  operation  may  be  commenced  and  completed 
with  a  safe-sided  file.  The  file,  during  the  operation,  should  be 
frequently  dipped  in  water,  to  prevent  it  from  becoming  heated 
or  clogged  while  in  use ;  having  the  water  warm  or  tepid  where 
the  teeth  are  sensitive.     When  the  file  becomes  so  much  clogged 


260 


FILING    TEETH. 


that  the  water  or  a  brush  will  not  cleanse  them,  a  brass  or  steel 
scratch-brush  may  be  used,  or  they  may  be  dipped  in  sulphuric 
or  chlorohydric  acid,  and  then  washed  with  the  greatest  care  to 
remove  every  trace  of  acid. 

Fig.  75. 


I 

i 


Fig.  75  represents  various  forms  of  the  thin  separating  file. 

To  secure  the  success  of  the  operation,  it  is  sometimes  neces- 
sary to  file  away  a  considerable  portion  of  the  tooth  ;  but  in 
doing  this,  the  operator  should  be  careful  not  to  destroy  the 
symmetry  of  the  labial  surface.  The  aperture,  anteriorly, 
should  only  be  wide  enough  to  admit  of  a  free  oblique  or  diagonal 
motion  of  a  safe-sided  file  of  about  one-fourth  of  a  line  in  thick- 
ness. In  this  way,  one-fourth  or  more  of  a  tooth  may  be  re- 
moved without  materially  altering  its  external  appearance.  But 
a  tooth  should  not  be  filed  entirely  to  the  gum  ;  a  shoulder 
shouldj^e  left  to  prevent  its  approximation  to  the  adjoining 
tooth.  Sometimes  the  decay  is  of  such  size  and  so  situated, 
that  it  may  be  removed  by  means  of  enamel  chisels  and  scrapers 
with  less  alteration  in  the  external  or  labial  surface  of  the  tooth. 
These  very  valuable  instruments  will  also  be  found  useful  for 
rapid  cutting  preparatory  to  the  slower  action  of  the  file.  A 
rounded  form  can  be  given  by  them  to  the  inner  angles  of  the 
teeth,  for  which  purpose  they  may  either  follow  or  take  the 
place  of  the  file. 

When  the  decay  occupies  a  large  portion  of  the  approximal 
surface,  and  has  penetrated  into  the  tooth  to  a  considerable 
depth,  destroying  the  enamel  anteriorly,  and  causing  it  to  pre- 
sent a  ragged  and  uneven  edge,  it  will  be  necessary  to  form  a 
wider  exterior  aperture  than  mere  regard  for  appearance  would 
dictate.  When  the  approximal  surfaces  of  the  two  front  teeth 
are  affected  with  caries,  about  an  equal  portion  should,  if  cir- 
cumstances permit,  be  filed  from  each  tooth.  In  the  case  of 
delicate  front  teeth  or  teeth  slightly  loose  in  their  sockets,  it  will 


FILING    TEETH. 


261 


Fig.  76. 


be  well  before  filing  to  mould  a  small  piece  of  gutta-percha 
around  or  against  the  inner  surfaces  of  the  tooth  to  be  filed  and 
several  adjoining  ones.  It  gives  support  to  frail  teeth,  and 
greatly  lessens  the  danger  of  irritation  from  the  motion  imparted 
by  the  file  to  teeth  which  are  not  firmly  set  in  their  sockets. 
Some  use  for  this  purpose  plaster ;  but  we  think  the  gutta- 
percha, as  suggested  by  Professor  Gorgas,  will  be  found  alto- 
gether more  conveniently  applied  and  more  agreeable  to  the 
patient. 

Fig.  76  represents  a  front  view  of  the  superior  incisors  and 
cuspids  after  having  been  filed,  showing  the  shoulder  left  near 
the  gum ;  which,  however,  should  not 
have  the  sharp  angle  represented  in  the 
drawing.  To  prevent  this,  the  operation 
may  be  completed  with  a  round-edged 
separating  file  or  else  with  a  delicate 
mouse-tail  file. 

After  a  sufiicient  portion  of  the  tooth  has  been  filed  away,  the 
surface  should  be  made  as  smooth  as  possible  with  a  very  fine  or 
half  worn  file,  or  with  Arkansas  stone,  finishing  with  pumice- 
stone  or  powdered  silex,  applied  upon  a  piece  of  cord,  tape,  or 
suitably  shaped  piece  of  hard,  tough  wood.  All  edges  and  sharp 
corners  should  be  rounded  and  made  smooth,  and  when  the 
operation  is  completed,  the  patient  should  be  directed  to  keep 
the  filed  surfaces  perfectly  clean  ;  for  if  the  mucous  secretions 
of  the  mouth,  or  extraneous  matter  is  permitted  to  adhere  to 
them,  a  recurrence  of  the  disease  will  take  place. 

In  Fig.  77  is  represented  a  posterior  view  of  the  superior  in* 
cisors    and   cuspids   after   having 
been  filed ;  also,  of  the  bicuspids 
and  molars  after  having  been  sub- 
jected to  the  same  operation. 

In  separating  the  bicuspids,  a 
space  should  be  made  somewhat 
in  the  form  of  the  letter  V;  it 
should  not,  however,  form  an 
acute  angle  at  the  gum  ;  for  its 
formation  a  file,  shaped  like  a 
clockmaker's  pinion-file,  or  one 
that  is  oval  on  one  side  and  flat 


Fig.  77. 


vX^'X 


262 


FILING    TEETH. 


on  the  other,  will  be  found  most  suitable.  A  space  shaped  in 
this  manner  will  prevent  the  approximation  of  the  sides  of  the 
teeth,  and  if  filling  be  necessary,  it  will  enable  the  operator  to 
do  it  in  the  most  perfect  manner. 

When  the  separation  of  the  molar  teeth  becomes  necessary, 
the  same  shaped  space  should  be  formed.  But  as  these  teeth 
are  situated  far  back  in  the  mouth,  it  cannot  often  be  done  with  a 
straight  file ;  to  obviate  this  difficulty,  an  instrument,  with  which 
every  dentist  is  acquainted,  denominated  a  file-carrier,  is  usually 
employed.  But  in  consequence  of  the  difficulty  of  procuring  in- 
struments of  this  kind,  exactly  suited  to  holding  files  of  the 
right  shape,  the  author,  a  few  years  ago,  sent  some  file  patterns 
to  Stubs'  manufactory,  in  England,  and  had  files  made,  which 
he  found  to  answer  his  fullest  expectations.  These  files  (Fig. 
78),  are  shaped  something  like  a  pinion  file  :   they  are  an  inch 

Fig.  78. 


and  a  half  long,  and  have  a  handle  of  about  six  inches  in  length, 
bent  in  such  a  manner  that  the  instrument  may  be  used  between 
the  molar  teeth  without  interfering  with  the  corners  of  the 
mouth.  They  are  in  pairs — one  for  the  right  and  one  for  the 
left  side   of  the  mouth.     Two  patterns  are   represented;   the 

Fig.  79. 


^biiBlilililiiiiiiiiiiliiiiliiliiiiiiiiii 


FILING    TEETH. 


263 


upper,  in  consequence  of  the  handle  being  on  a  line  with  the 
file,  works  more  easily  than  the  lower  one. 

A  great  variety  of  V  shaped  separating  files  are  now  to  be 
found  in  the  dental  depots,  from  English,  French,  and  American 
manufacturers.  Fig.  79  will  give  a  correct  idea  of  some  of 
these  shapes. 

Fig.  80  represents  a  very  useful  file-carrier  invented  by  Dr. 
A.  Westcott :    c   is   a   spring,  and   through   the   arms  a  and  6, 

Fig.  80. 


there  are  square  mortices  to  receive  the  ends  of  the  file  and  to 
keep  it  from  turning.  The  arm  h  comes  ofi"  at  an  obtuse  angle. 
The  file  is  prepared  by  making  each  end  square,  corresponding 
with  the  size  of  the  mortices  in  the  arms,  and  is  adjusted  to  the 
carrier  by  first  putting  one  end  of  the  file  into  the  arm  a,  and 
pressing  down  the  other  end  into  the  mortice  h  ;  the  spring,  con- 
stituting that  portion  of  the  instrument  between  the  arms,  yields 
sufficiently  to  admit  of  this.  It  is  so  constructed  that  the  handle 
is  brought  on  a  line  Avith  the  file — consequently  two  are  required, 
one  for  each  side  of  the  mouth. 

Fig.  81. 


Fig.  81  represents  an  excellent  file-carrier,  in  which  the  file 
can  with  ease  be  set  at  any  required  angle,  and  will  suit  either 
side  of  the  mouth. 


CHAPTER    THIRD. 

FILLING  TEETH. 

This  is  one  of  the  most  difficult  operations  the  dentist  is 
called  upon  to  perform ;  it  often  baffles  the  skill  of  operators 
who  have  been  in  practice  many  years.  It  is  advisable  only 
under  certain  circumstances,  and  when  the  operation  is  per- 
formed without  due  regard  to  these,  it  may  be  productive  of 
injury  rather  than  benefit.  It  is  the  only  certain  remedy  that 
can  be  applied  for  arresting  the  progress  of  deep-seated  caries; 
but  to  be  effective,  it  must  be  executed  in  the  most  thorough  and 
perfect  manner.  The  preservation  of  a  tooth  may  be  regarded 
as  certain  when  well  filled,  and  with  a  suitable  material,  if  it  be 
afterwards  kept  constantly  clean.  At  any  rate,  it  will  never 
again  be  attacked  by  caries  in  the  same  place. 

On  this  highly  important  operation,  Dr.  E.  Parmly  thus  re- 
marks: "If  preservation  is  as  good  as  a  cure,  this  is  as  good  as 
both ;  for  the  operation  of  stopping,  when  thoroughly  performed, 
is  both  preservation  and  cure.  And  yet  it  must  never  be  forgotten, 
that  this  assertion  is  true  only  in  those  instances  in  which  the 
operation  is  well  and  properly  done;  and,  perhaps,  it  is  im- 
perfectly and  improperly  performed  more  frequently  than  any 
other  operation  on  the  teeth. 

"  There  are  reasons  for  this  fact,  into  which  every  ambitious 
and  honorable  practitioner  will  carefully  inquire.  Although  the 
books  are  explicit  on  this  point,  I  deem  it  sufficiently  important 
to  deserve  a  few  additional  remarks.  The  following  considera- 
tions are  essential,  and,  therefore,  indispensable  to  success  in 
this  department  of  practice.  Firstly — The  instruments  used 
must  be  of  the  proper  construction  and  variety.  Secondly — The 
metal  employed  must  be  properly  prepared  as  well  as  properly 
introduced.  Thirdly — The  cavity  which  receives  the  metal, 
must  be  so  shaped  as  to  retain  it  in  such  a  manner  as  to  exclude 
not  only  solids,  but  all  fluids,  and  even  the  atmosphere  itself. 


FILLING    TEETH.  265 

Fourthly — The  surface  of  the  metal  must  be  left  in  such  condi- 
tion as  to  place  it  beyond  the  reach  of  injury  from  food  and 
other  mechanical  agents  with  which  it  necessarily  comes  in  con- 
tact. Fiftldy — The  tooth  thus  stopped  should  be  free  from  pain, 
and  every  known  cause  of  internal  inflammation." 

It  is  important  that  the  operation  be  performed  before  the 
disease  has  reached  the  pulp  cavity ;  after  this,  the  permanent 
preservation  of  the  tooth  may  be  regarded  as  more  or  less  ques- 
tionable. Still,  under  favorable  circumstances,  the  author  be- 
lieves it  may,  in  the  majority  of  cases,  be  performed  with  success. 
But,  as  the  propriety  and  manner  of  filling  a  tooth  after  the  pulp 
has  become  exposed,  will  hereafter  come  up  for  special  consider- 
ation; as  well,  also,  as  the  operation  of  filling  the  pulp  cavity 
after  the  destruction  of  the  pulp;  it  will  not  be  necessary  to 
enlarge  upon  these  subjects  at  this  time. 

A  tooth  is  sometimes  exceedingly  sensitive  when  the  nerve  is 
not  exposed ;  but  this  need  not  deter  the  operator  from  removing 
the  decayed  part  and  filling  the  cavity,  as  the  only  inconvenience 
it  will  occasion  the  patient,  will  be  a  little  sufi'ering  during  the 
operation,  and  slight  momentary  pain  for  a  few  days,  whenever 
any  thing  hot  or  cold  is  taken  into  the  mouth.  But  when  the 
sensibility  is  so  great  that  the  patient  cannot  bear  the  removal 
of  the  diseased  part,  as  occasionally  occurs,  it  may  be  allayed 
by  the  application  of  chloride  of  zinc  to  the  cavity  of  the  tooth, 
for  from  three  to  six  minutes.  When  this  is  done,  care  should 
be  taken  to  prevent  it  from  coming  in  contact  with  any  of  the 
soft  parts  of  the  mouth,  on  account  of  its  active  escharotic 
properties.  The  fortieth  or  fiftieth  part  of  a  grain  of  arsenic  is 
sometimes  applied,  but  there  is  great  danger  of  destroying  the 
vitality  of  the  pulp  by  the  use  of  this  agent,  even  though  it  be 
permitted  to  remain  for  only  a  few  hours.  Cobalt  is  said  to  be 
less  dangerous  and  equally  efficacious. 

Chloroform  applied  to  the  cavity  on  a  small  piece  of  cotton 
will  often  give  a  temporary  insensibility,  and  has  the  merit  of 
being  quite  harmless;  which  cannot  be  said  of  chloride  of  zinc, 
arsenic,  or  cobalt — the  first  sometimes  acting  injuriously  upon 
the  dentine,  the  two  latter  upon  the  dental  pulp.  The  safest 
and  perhaps  best  way  of  meeting  the  difficulty,  is  to  have  the 
excavators  very  sharp  and  well  tempered,  and  to  cut  firmly  and 
18 


266  MATERIALS    EMPLOYED    FOR    FILLING   TEETH. 

decidedly;   for  the  scraping  of  a  dull  instrument  is  quite  as 
painful  as  the  cut  of  a  sharp  one. 

Again,  this  acute  sensitiA-eness  of  dentine  is  due  to  the  presence 
of  nerve  fibres,  as  conjectured  by  Dr.  Maynard,  and  demon- 
strated by  Professor  Johnston  (see  page  50) ;  therefore,  we  shall 
save  the  patient  much  suiFering  by  making  the  first  strokes  of 
the  instrument  in  such  direction  as  to  sever  these  fibres,  as  recom- 
mended by  Dr.  Maynard. 


MATERIALS  EMPLOYED  FOR  FILLING  TEETH. 

Among  the  articles  which  have  been  employed  for  filling  teeth, 
are  gold,  platina,  silver,  tin,  lead;  fusible  alloys  of  tin,  lead,  bis- 
muth and  cadmium ;  amalgams,  gutta  percha,  oxy-chloride  of  zinc, 
and  various  preparations  of  the  gum-resins.  Of  these  no  single 
one  can  be  said  to  unite  all  the  requirements  of  a  perfect  material 
for  filling,  •which  may  be  enumerated: — 1.  Resistance  to  the 
mechanical  action  of  mastication.  2.  Resistance  to  the  chemi- 
cal agencies  of  the  mouth.  3.  Facility  of  introduction  and 
consolidation.  4.  Harmony  of  color.  5.  Absence  of  all  gal- 
vanic, chemical  or  vital  action  upon  the  teeth  or  the  general 
system.     6.  Absence  of  all  heat-conducting  property. 

Gold  Foil. — To  the  use  of  this  material,  when  properly  pre- 
pared, there  is  the  least  possible  objection :  perfectly  answering 
the  first,  second,  and  fifth  requirements ;  to  a  great  extent  the 
third,  if  in  skillful  hands;  but  deficient  in  the  fourth  and  sixth. 
It  is  the  only  one,  in  the  opinion  of  the  author,  which  should 
ever  be  employed  for  the  permanent  filling  of  teeth.  No  better 
material  is  wanted  for  the  operation.  A  tooth  may  be  so  tilled 
with  it  as  to  secure,  in  almost  every  case,  its  permanent  preser- 
vation. It  should,  however,  be  perfectly  pure,  be  beaten  into 
thin  leaves,  and  well  annealed  before  it  is  used.  When  pre- 
pared in  this  manner,  it  may  be  pressed  into  all  the  inequalities 
of  the  cavity,  and  rendered  so  firm  and  solid  as  to  be  imperme- 
able to  the  fluids  of  the  mouth.* 

*  It  would  seem  from  what  Fauchard  says  upon  the  subject,  {Le  Ghirurgien  Dentiste, 
tome  2,  pp.  68-70,)  that  this  metal,  to  some  extent  at  least,  has  been  used  for  filling 
teeth  for  a  long  time.     Although  he  gives  the  preference  to  tin  and  lead,  on  accouni 


MATERIALS    EMPLOYED    FOR    FILLING    TEETH.  267 

■  Although  there  may  be  no  difference  in  the  purity  of  the  gold, 
and  the  thickness  of  the  leaves ;  yet  a  marked  difference  will  be 
found  to  exist  in  the  malleability  and  toughness  of  the  foil  of 
different  beaters.  The  art  of  preparing  gold  for  filling  teeth  is 
an  exceedingly  nice  and  difficult  one,  and  is  believed  to  have 
attained  greater  perfection  in  the  United  States  than  in  any 
other  country ;  at  least  this  fact  is  so  generally  admitted,  that 
many  of  the  most  eminent  European  practitioners  procure  nearly 
all  they  use  from  Mr.  Charles  Abbey,  of  Philadelphia,  the  oldest 
manufacturer  in  America.  There  "are,  however,  many  other  gold 
beaters  in  the  United  States  who  manufacture  gold  foil  of  a  very 
excellent  quality. 

The  thickness  of  the  leaves  is  determined  by  the  number  of 
grains  each  contains,  and  is  designated  by  numbers  on  the  books, 
between  the  leaves  of  which  they  are  placed,  after  having  been 
properly  annealed.  These  numbers  range  from  4  to  20.  The 
weight  of  the  leaves,  generally,  varies  two  grains,  so  that  the 
numbers  run,  4,  6,  8,  10,  and  so  on  up  to  20.  A  book  contain- 
ing a  quarter  of  an  ounce  of  No.  4,  will  have  thirty  leaves  in  it. 
Some  dentists  use  foil  varying  in  Nos.  from  4  up  to  20,  while 
others  confine  themselves  to  a  single  number.  If  but  one  num- 
ber be  used,  4  will,  perhaps,  be  found  better  than  any  other.  The 
author  has  used  Nos.  4,  6,  8,  10  and  15,  but  he  prefers  the  first, 
and  is  decidedly  of  opinion,  that  in  a  large  majority  of  cases,  a 
better  filling  can  be  made  with  it  than  any  of  the  others.  There 
may  be  cases  in  which  higher  numbers  can  be  more  advanta- 
geously employed  ;  as  for  instance  in  fang  filling,  and  in  cavities 
which  are  either  very  large  or  very  small. 

Foil  manufactured  from  sponge  or  crystalline  gold,  is  so  ad- 
hesive, that  any  number  of  pieces  may  be  welded  one  to  another  ; 
thus  a  part,  or  even  the  whole  of  the  crown  of  a  tooth,  may  be 
built  up  with  it.  The  same  properties  may  also  be  imparted  to 
foil  manufactured  in  the  ordinaa^y  way,  by  re-annealing.  This 
property  is  peculiarly  valuable  in  many  cases  where  it  becomes 

necessary  to  build  up  a  large  portion  of  the  crown  of  a  tooth ; 

of  the  greater  malleability  of  these  metals,  ho  speaks  of  gold  as  being  used  by  other 
dentists.  But  the  operation  of  filling  teeth,  at  the  time  this  author  wrote,  was  very 
imperfectly  understood,  and  the  gold  then  employed  for  the  purpose  must  have  been 
so  badly  prepared  as  to  render  its  use  exceedingly  difficult. 


268  MATERIALS    EMPLOYED    FOR    FILLING    TEETH. 

but  when  it  is  used,  instruments  having  serrated  points  are  re- 
quired, like  those  employed  in  the  use  of  crystalline  gold.  But 
for  filling  ordinary  cavities  in  teeth,  this  property  is  of  no  ad- 
vantage ;  indeed,  for  filling  a  deep  cavity,  having  an  orifice  no 
larger  than  the  bottom,  it  is  objectionable,  as  more  time  and  labor 
is  required  to  reach  the  same  point  of  excellence  with  it,  than 
with  foil  such  as  is  usually  obtained  from  the  best  manufac- 
turers.* 

Sponge  or  Crystalline  Gold  has  recently  been  employed  by 
some  dentists  for  filling  teeth.  The  author  has  used  it  in  a  num- 
ber of  cases  with  very  satisfactory  results.  Since  the  publica- 
tion of  the  fifth  edition  of  this  work,  the  properties  of  crystalline 
or  sponge  gold  have  been  more  thoroughly  and  extensively  tested, 
and  the  result,  especially  with  the  last  named  preparation,  has 
fully  confirmed  the  favorable  opinion  entertained  by  us  with  re- 
gard to  its  value.  Those  who  have  had  most  experience  in  the 
use  of  it,  say  it  is  superior,  in  many  cases,  to  foil.  The  author 
is  acquainted  with  several  of  the  most  skillful  operators  in  the 
United  States,  who  have  used  it  almost  exclusively  in  their  prac- 
tice for  several  years ;  and  has  seen  fillings  made  by  some  of 
these  gentlemen,  which  for  beauty  and  solidity  he  does  not  think 
could  be  surpassed.  He  has  also  himself  made  some  fillings 
with  this  material,  which  he  believes  it  would  be  impossible  to 
make  with  ordinary  gold  foil.  The  crystals  possess  the  property, 
when  pressed  firmly  against  each  other,  of  welding  and  becoming 
as  solid  and  almost  as  incapable  of  disintegration  or  crumbling 
as  a  piece  of  bullion  or  coin.  This  property  enables  a  skillful 
manipulator  to  supply  almost  any  loss  which  a  tooth  may  have 
sustained,  even  to  the  building  up  of  an  entire  crown.  Still  it 
will  never  supersede  the  use  of  non-adhesive  gold  foil,  as  there 
are  many  cases  in  which  the  latter  can  be  used  more  advan- 
tageously and  with  more  facility  than  the  former.  Nor  will  the 
employment  of  it,  in  the  opinion  of  the  author,  ever  become  uni- 
versal ;  for  the  reason  that  more  care  and  skill  are  required  to 

■*"  Ailhesive  gold  foil  has  been  known  to  some  dentists  for  many  years,  but  Dr.  R- 
Arthur  was  the  first  to  describe  the  proper  manner  of  using  it  (A  treatise  on  the  Use 
of  Adhesive  Gold  Foil,  1857).  He  claims  that  the  same  point  of  excellence  can  be  at- 
tained with  it  as  with  the  best  preparations  of  crystalline  gold. 


I 


MATERIALS   EMPLOYED    FOR    FILLING   TEETH.  269 

make  a  good  filling  with  it  than  with  leaf-gold,  especially  when 
the  cavity  in  the  tooth  is  difficult  of  access.  Filling  with  crystal 
gold  or  adhesive  foil,  especially  the  latter,  is  more  tedious  than 
the  same  operation  with  ordinary  foil.  Again,  the  necessity  of 
excluding  saliva  from  the  filling  during  the  operation  is  im- 
perative ;  for  the  slightest  moisture  destroys  the  adhesiveness  of 
the  material,  upon  which  depends  the  success  of  the  operation. 

Experiments  have  been  made  with  silver,  platina  and  alumi- 
nium ;  but  with  unsatisfactory  results.  They  are  less  malleable 
than  gold,  and  therefore  cannot  be  made  so  thin  ;  at  the  same 
time  they  have  not  the  softness  of  tin  ;  hence  they  work  harshly 
under  the  plugger.  But  for  this,  platina  would  prove  a  very 
valuable  material.  An  additional  objection  to  silver  is  its  lia- 
bility to  undergo  chemical  change,  being  in  this  respect  greatly 
inferior  to  pure  tin.  The  peculiarity  of  aluminium,  in  this  rela- 
tion, is  the  impossibility  of  welding  its  leaves  by  pressure  :  even 
under  the  gold  beater's  hammer  it  forms  loose  scales  which  no 
annealing  can  make  adherent. 

Tin  Foil. — This,  when  chemically  pure,  and  properly  pre- 
pared, is  less  objectionable  for  filling  teeth,  than  most  of  the 
articles  hereafter  enumerated.  Under  favorable  circumstances, 
if  skillfully  introduced,  it  will  prevent  the  recurrence  of  caries. 
But  if  the  fluids  of  the  mouth  are  vitiated,  it  soon  oxidizes  and 
turns  black  ;  and  then,  instead  of  preventing,  it  rather  promotes 
a  recurrence  of  the  disease.  This,  with  the  author,  has  consti- 
tuted an  insuperable  objection  to  its  use.  As  an  excuse  for  its 
employment,  however,  many  operators  say,  that  in  consequence 
of  its  greater  softness,  it  can  oftentimes  be  employed  for  filling 
a  badly-shaped  and  large  cavity  where  gold  cannot  be  used.  We 
do  not,  however,  regard  this  as  a  valid  objection;  for  any  tooth 
that  can  be  filled  with  tin,  can  be  equally  well  filled  with  gold. 
Others  again  employ  it,  because  many  of  their  patients  are  not 
able  to  pay  for  a  more  costly  material.  Now,  if  a  tooth  is  worth 
filling  at  all,  it  is  worth  filling  in  a  proper  manner,  and  with  a 
suitable  material,  and  it  would  be  more  creditable  to  the  operator 
to  divide  the  expense  with  his  poor  patient,  than  to  use  an  article 
that  may  never  benefit  him. 

Lead  is  far  more  objectionable  than  tin,  as  it  is  more  easily 


270  MATERIALS    EMPLOYED    FOR   FILLING   TEETH. 

decomposed  by  the  secretions  of  the  mouth  ;  its  introduction  into 
the  stomach  might  be  productive  of  serious  injury  to  the  general 
health  of  the  patient.  But,  happily,  this  article  is  now  seldom 
used,  except  by  the  most  ignorant  and  lowest  class  of  empirics. 

D'Arcefs  3Ietal,  an  alloy  of  tin,  lead  and  bismuth  was  once 
empirically  used  in  a  fused  state.  But  two  serious  objections 
compelled  its  abandonment.  The  high  temperature  (212°)  caused 
great  pain  and  excited  inflammation.  If  from  this  cause  the 
tooth  was  not  lost,  the  shrinkage  of  the  metal  on  cooling  admit- 
ted moisture  into  the  cavity  and  the  decay  progressed. 

The  attention  of  the  profession  has  recently  been  called  to  a 
somewhat  similar  alloy,  discovered  by  Dr.  B.  Wood.  The  feature 
of  Dr.  Wood's  discovery  is  the  remarkable  property  of  cadmium 
in  reducing  the  fusion  point  of  the  fusible  alloys.  This  over- 
comes in  good  measure  the  first  objection  against  D'Arcet's 
metal,  and  the  second  perhaps  altogether.  It  may  be  introduced 
in  properly  sized  pieces,  cold  ;  then  made  plastic  and  pressed  to 
place  with  blunt  instruments  suitably  shaped  and  heated  to  the 
proper  temperature.  Over  a  sensitive  pulp,  a  layer  of  non-con- 
ducting asbestos  may  be  interposed.  The  merits  of  this  applica- 
tion of  Dr.  Wood's  otherwise  very  valuable  discovery,  have 
scarcely  had  a  sufficient  test.  We  cannot  speak  from  any  ex- 
perience in  its  use  ;  but  should  think  that  it  might  be  experimented 
with  in  certain  cases,  Avhere  the  use  of  gold  is  inadmissible, 
and  where  there  is  little  or  no  danger  of  irritation  from  the  ele- 
vated temperature  necessary  to  its  use. 

Amalgam,  also  known  by  the  name  of  mineral  cement,  or 
lithodeon,  is  the  most  pernicious  material  that  has  ever  been 
employed  for  filling  teeth.  It  almost  always  oxydizes  in  the 
mouth,  turning  the  teeth  black,  and  often  hastens  their  destruc- 
tion. When  used  in  considerable  quantity,  it  is  apt  to  exert  a 
deleterious  effect  upon  the  alveolo-dental  membranes,  gums,  and 
other  parts  of  the  mouth. 

In  the  first  edition  of  this  work,  the  author  expressed  his  dis- 
approbation of  the  employment  of  this  article ;  since  which  time 
he  has  had  abundant  opportunity  of  observing  its  eifects,  and  is 
fully  confirmed  in   the  unfavorable  opinion  which  he  then  ex- 


MATERIALS    EMPLOYED    FOR   FILLING   TEETH.  271 

pressed  with  regard  to  it.  Several  decided  cases  of  salivation, 
occasioned  by  the  use  of  it,  have  fallen  under  his  observation. 

Some  have  endeavored  to  obviate  the  objections  existing  to  its 
use,  by  employing  silver  perfectly  pure  ;  but  it  matters  not  how 
pure  this  metal  may  be,  the  amalgam  is  equally  deleterious  in 
its  effects,  for  the  mercury  is  the  mischievous  ingredient. 

The  amalgam  most  recently  approved  by  its  advocates  is  made 
by  mixing  mercury  with  filings  of  an  alloy  of  silver  and  tin. 
Great  care  is  used  to  press  out  all  excess  of  mercury  through 
buckskin,  and  to  wash  out  all  the  oxide  in  alcohol,  &c.  Its 
friends  claim  for  it,  thus  carefully  prepared,  that  it  will  not  often 
blacken  the  teeth,  and  that  very  little  if  any  free  mercury  can 
escape  into  the  tooth  or  the  mouth. 

That  it  is  a  very  convenient  material ;  can  be  put  where  gold 
cannot;  becomes  very  hard  and  may  last  for  many  years,  w'e 
doubt  not ;  but  nothing  we  have  seen,  read,  or  heard,  can  per- 
suade us  that  the  profession  would  not  have  been  benefited  if 
mercurial  amalgams  had  never  been  known. 

Gum  Mastic,  at  one  time  much  used,  is  now  seldom  employed, 
except  as  a  temporary  filling  when  the  pulp  of  the  tooth  is  ex- 
posed ;  even  for  this  purpose  it  requires  to  be  often  renewed,  as 
it  is  soon  dissolved  by  the  saliva. 

An  alcoholic  solution  of  Gum  Sandarach  or  Mastic,  is  some- 
times used  to  retain  arsenical  preparations  in  the  cavity  for  the 
destruction  of  a  nerve.  A  piece  of  cotton  saturated  with  the 
solution  is  readily  introduced,  hardens  quickly,  and  may  keep  its 
place  for  several  days  if  required. 

Gutta  Percha  is  an  excellent  material  for  temporary  fillings. 
It  may  be  made  harder,  whiter  and  less  contractile  by  incorpo- 
rating with  it  some  very  fine  powder  of  feldspar,  silex,  lime  or 
magnesia.  A  very  excellent  preparation  known  as  Hill's  stop- 
ping is  made  by  mixing  gutta  percha  with  as  much  of  the  follow- 
ing powder  as  it  will  hold  without  becoming  brittle — quicklime, 
two  parts,  very  fine  quartz  and  feldspar,  one  part  each.  Of  all 
temporary  fillings  this  is  probably  the  best  yet  known. 

A  mixture  of  chloride  of  zinc  and  oxide  of  zinc,  has  been 
lately  much  used  under  the  various  names  of  oxy-chloride  of  zinc, 


079 


INSTRUMENTS    FOR    FORMING   THE   CAVITY. 


osteo-dentine,  osteo-plastic,  mineral  paste,  &c.  Quackery  has 
seized  it  with  eagerness  and  plastered  up  many  teeth  with  a 
mortar  even  more  conveniently  used  than  amalgam.  The  chloride 
in  it  ^vill  injure  the  tooth  substance  in  some  cases.  It  may  last 
for  some  time  in  a  cavity,  but  it  often  crumbles  away  in  a  few 
weeks  or  months.  Still  as  a  temporary  filling  it  may,  if  employed 
with  caution  and  judgment,  be  found  useful,  and  for  certain 
cases  very  valuable. 


INSTRUxMENTS  FOR  FORMING  THE  CAVITY. 

For  the  removal  of  the  diseased  part  of  a  tooth,  and  the 
formation  of  a  cavity  for  the  proper  reception  and  retention  of  a 
filling,  a  variety  of  instruments  are  required,  which  should  be 
constructed  of  the  best  steel,  and  so  tempered  as  to  prevent  them 
from  either  breaking  or  bending.  Their  points  should  be  so 
shaped,  that  they  may  be  conveniently  applied  to  any  part  of  a 
tooth,  and  made  to  act  readily  upon  the  portion  which  it  is  neces- 
sary to  remove. 

The  instruments  employed  for  this  purpose  are  called  excava- 
tors.    They  may  be  formed  either  with  handle  and  point  in  one 

piece ;  or  fitted  to  se- 
FiG.  82.  ^  ,        „ 

parate   handles    made 

of  wood,  ivory,  pearl 
or  cameo ;  or  be  made 
to  fit  into  one  common 
socket  handle.  Those 
having  separate  han- 
(j/  dies  are  more  conve- 
nient than  the  others, 
but  it  would  be  well  for 
every  practitioner  to 
be  provided  with  a  num- 
ber of  each  kind.  Steel- 
handled  excavators  are 
cheaper  than  wooden 
or  ivory-handled  ones ; 
but  if  small  they  are  not  so  easily  grasped,  and  if  large  they 
become  too  heavy.     The  handle  best  suited  for  delicate  manipu- 


IXSTRUMENTS    FOR    FORMING    THE    CAVITY.  273 

lation  is  made  of  cocoa  or  ebony,  largest  an  inch  above  the 
ferule,  and  tapering  both  ways.  The  principle  of  construction 
is  to  give  suflBcient  size  for  the  fingers  to  hold  it  securely,  and  to 
lessen  the  weight  at  the  end  of  the  handle.  Socket  handles  are 
useful  for  those  who  wish  compactness  of  apparatus ;  also  for 
those  who  are  in  the  habit  of  pointing  their  own  instruments. 
Fig.  83  represents  such  an  instrument:  the  lower  one  made  of 

Fig.  83. 


ivory,  ebony  or  cocoa,  will  be  found  very  valuable.  Its  shape 
might  be  better  suited  to  some  operators  if  made  somewhat  larger 
just  above  the  ferule. 

The  flat  and  burr-headed  drills  are  very  useful  for  enlarging 
the  orifice  of  a  cavity.  The  pressure  of  the  instrvmient  against 
the  hand,  between  the  thumb  and  fore-finger,  is  often  produc- 
tive of  much  irritation.  To  prevent  which,  a  socket  ring  or 
shield  like  the  one  represented  in  Fig.  82,  invented  by  Dr. 
Westcott,  may  be  used  with  advantage.  It  consists  of  a  ring 
adapted  to  the  fore  or  middle  finger,  with  a  small  socket  attached 
to  the  inside. 

The  author  uses  an  open  ring  like  the  one  represented  in  Fig. 
84,  with  an  arm  a  little  more  than  an  inch  in  length  attached, 
having  a  socket  at  the  extremity  resting  in  the  „     „ , 

hollow  of  the  hand,  between  the  thumb  and 
fore-finger.  This  he  finds  much  more  conve- 
nient, as  it  enables  him  to  apply  more  pressure 
upon  the  instrument  without  irritating  the  finger, 
and  as  the  ring  is  open,  it  adapts  itself  more 
readily  to  it. 

A  socket  handle  may  also  be  used  for  drills  as 
for  excavators.  It  may  be  shaped  like  the  ex- 
cavator socket  (Fig.  83),  with  the  end  of  the 
handle  pointed  so  as  to  fit  into  the  ring  (Figs. 
82,  84);  or  it  may  have  a  flattened,  revolving  head.  The  bits 
may  be  fitted  either  by  firmly  pressing  them  into  a  simple  round 
socket,  or  a  trigger  socket  may  be  used. 


274 


INSTRUMENTS    FOR    FORMING   THE    CAVITY. 


Fig.  85. 


Dr.  Forbe.s  has  adapted  to  enamel  burrs,  chisels  and  gouges, 
an  ingeniou.s  handle,  which,  by  the  simple  turning  of  a  small 
wrench,  secures  the  square-cornered  bits  very  firmly  (Fig.  85). 

The  principle  may  be 
applied  to  handles  of 
different  shapes  and 
sizes,  provided  they 
are  not  too  small. 

The  old  fashioned 
bow-and-string    drill 
is  now  disused;  part- 
ly because  of  its  for- 
midable   appearance, 
but  chiefly  because  there  is  danger  of  revolving  it  with  too  great 
rapidity.     Many  very  ingenious  forms  of  drill-stocks  have  been^ 
from  time  to  time,  invented;  of  these  we  present  several. 

The  instrument  represented  in  Fig.  86  is  a  modification  of  a 

Fig.  86. 


very  ingeniously  contrived  drill-stock  invented  by  Dr.  Maynard. 
for  opening  a  cavity  in  the  grinding,  buccal  or  posterior  approx- 
imal  surface  of  a  molar  tooth.  It  is  so  constructed  as  to  move 
a  drill,  pointing  in  three  different  directions;  but,  as  in  the  case 
of  the  drill-stock  used  with  a  bow,  the  orijiinal  instrument  re- 
quired  both  hands  to  work  it.  To  obviate  which  difficulty,  it  has 
been  so  improved  that  it  may  be  used  with  one  hand,  as  shown 
in  the  above  engraving. 

Two  drill-stocks  were  presented  to  the  author  some  years  ago, 
the  first  (Fig.  87)  by  Dr.  James  Robinson,  of  London,  invented 
by  Mr.  McDowell,  of  Lincoln  Inn  Fields.  It  is  upon  the  prin- 
ciple of  the  helix.  A  drill-stock,  inserted  ut  the  end  of  the 
screw,  is  moved  by  means  of  a  female  screw  attached  to  the 
handle  of  the  instrument.     As  may  be  seen  from  the  engraving, 


INSTRUMENTS    FOR    FORMING    THE    CAVITY. 

Fig.  87. 


275 


drills,  pointing  in  three  directions,  may  be  worked  in  it.  The 
other  was  presented  by  Mr.  John  Lewis,  formerly  of  Burlington, 
Vt.     (Fig.  88.)     It  is  a  beautiful  and  ingeniously  contrived  in- 


FiG.   88. 


strument.  The  drill  may  be  worked  in  any  direction  within  its 
circle  of  motion,  from  the  line  of  the  handle  round  to  the  same 
line  again. 

Merry's  drill-stock  (Fig.  89),  more  recently  invented,  is  sim- 


FiG.   89. 


pier  than  the  preceding,  and  will,  doubtless,  prove  useful  in  cases 
where  such  instruments  are  necessary. 

For  opening  a  cavity  in  the  grinding  surface  of  a  tooth,  par- 
tially covered  by  projecting  portions  of  the  enamel,  the  rose  or 
burr-headed  drill  is  invaluable,  and  it  can  often  be  advantage- 
ously applied  to  the  side  of  a  tooth.  There  are  many  cases, 
too,  where  the  flat  triangular-pointed  drill  can  be  conveniently 
employed,  as,  for  example,  when  it  becomes  necessary  to  extend 
the  cavity  further  into  the  tootli  than  the  disease  has  penetra- 
ted. When  the  drill  is  used,  it  should  be  frequently  dipped 
in  water  to  prevent  its  becoming  heated  by  the  friction  against 
the  tooth ;  this  precaution  ought  never  to  be  neglected. 


276  INSTRUMENTS    FOR    FORMING    THE    CAVITY. 

A  three-sided  instrument  brought  to  a  point  (Fig.  90),  as  also 
a  chisel-edged  (Fig.  91),  and  a  four-sided  one  with  a  cutting 

Fig.  90. 


Fig.  91.  Fig.  92. 

\i  .11— ,1^  1^ 


edge   (Fig.  92),  may  often  be  used  advantageously  in  cutting 

away  portions  of  enamel  to  enlarge  the  orifice.     Enamel-chisels 

of  other  shapes   and  gouges  are  also  very  valuable  instruments 

Pj^  c,2  ^^^  ^^^®  preliminary  operation  of  opening 

large  cavities,  or  cutting  off  sound  enamel 

"•  or  dentine  whenever  necessary.  Dr.  Forbes, 

b.^^^^  ^  of  St.  Louis,  has  devised  a  series  of  very 

- —  i     useful   forms   of  the   enamel  gouge  which 

are  adapted  to  the  handle  in  Fig,  85. 
But  the  cavity  can  seldom  be  completed 

with  either  of  the  instruments  mentioned 

above.  After  it  has  been  opened,  and  the 
a.^ —    -^  -^     orifice  made  sufficiently  large,  it  should  be 

finished  with  flat  or  curve-pointed  excava- 
tors (Fig.  93),  properly  adapted  to  the  purpose  ;  in  fact,  in  the 
majority  of  cases,  it  should  be  wholly  formed  with  instruments 
of  this  sort. 

Excavators,  shaped  like  those  represented  in  Fig.  93,  have 
been  found  by  the  author  to  be  as  well  adapted  to  the  removal 
of  caries  as  any  which  he  has  ever  employed.  There  should  be 
several  sizes  of  each  shape ;  also  duplicates  of  each  instrument, 
to  prevent  delay,  in  case  of  accident  while  operating.  As  the 
proper  formation  of  the  cavity  greatly  depends  on  having  suit- 
able instruments,  every  operator  should  be  provided  with  a 
large  supply  of  burr-drills  and  excavators,  so  that  he  may  never 
be  at  a  loss  for  such  as  the  peculiarity  of  any  case  may  require. 
He  should  also  have  the  material,  and  know  how,  in  an  emer- 
gency, to  point  his  own  excavators.  For  this  purpose  he  will 
need  a  lamp,  a  small  anvil  and  hammer,  a  set  of  fine  cut  files 
such  as  are  used  by  watchmakers,  and  an  assortment  of  steel 


MANNER   OF   FORMING    THE  CAVITY.  277 

rods  of  various  sizes  and  of  the  best  quality.  It  is  not  our  pur- 
pose to  give  specific  directions  for  working  steel ;  but  we  would 
offer  two  cautions :  first,  small  points  quickly  become  brittle  by 
hammering  and  need  frequent  annealing;  second,  steel  is  greatly 
injured  by  raising  it  to  a  full  red  or  white  heat.  A  very  fine 
temper  may  be  given,  after  shaping  the  point,  by  heating  to  red- 
ness and  suddenly  plunging  it  in  wax  or  tallow; 

As  excavators  must  be  kept  very  sharp,  an  oil  stone  should  be 
constantly  at  hand.  The  Arkansas  stone  is  superior  for  this 
purpose  to  all  other  varieties,  on  account  of  its  hardness,  fineness 
and  sharpness  of  grit. 

) 
MANNER  OF  FORMING  THE  CAVITY. 

The  preparation  of  the  cavity  in  a  tooth  for  the  reception  of 
a  filling,  is  a  very  essential  part  of  the  operation,  and  though 
usually  the  easiest,  is  sometimes  attended  with  much  difficulty. 
The  removal  of  the  diseased  part  is  sometimes  all  that  is  neces- 
sary, preparatory  to  the  introduction  of  the  gold  :  but  in  the 
majority  of  cases  the  cavity  must  be  so  shaped,  as,  when  properly 
filled,  to  retain  the  filling  in  place.  The  part  of  the  tooth  sur- 
rounding the  orifice  should  present  no  rough  or  brittle  edges. 
The  size  of  the  bottom  of  the  cavity  should  be  as  near  that  of  the 
orifice  as  is  possible,  even  a  little  larger  rather  than  any  smaller. 
But  the  difference  between  the  size  of  the  one  and  the  other 
should  never  be  very  great ;  for  if  the  interior  of  the  cavity  is 
much  larger  than  the  orifice,  it  will  be  difficult  to  make  the  fill- 
ing sufficiently  firm  and  solid  to  render  it  absolutely  impermeable 
to  the  fluids  of  the  mouth.*  If,  on  the  other  hand,  the  orifice 
is  larger  than  the  bottom  of  the  cavity,  it  will  be  difficult  to  obtain 
sufficient  stability  for  the  filling,  so  as  to  prevent  it  from  ulti- 
mately loosening  and  coming  out.     It  often  happens,  however, 

*  Place  a  lump  of  cotton  in  the  hollow  of  the  hand  formed  by  briDging  the  ends  of 
the  fingers  against  the  palm.  Then  press  with  an  instrument  upon  the  centre  of  the 
cotton  and  it  will  leave  the  sides  of  the  cavity.  This  simple  illustration,  suggested  by 
Dr.  Edward  Maynard,  will  explain  the  cause  of  failure,  in  certain  cases  which  have  come 
under  his  notice,  from  the  hands  of  operators  of  deservedly  high  reputation. 

The  cavity,  smallest  at  the  orifice,  had  been  well  filled;  but  the  final  compression 
upon  the  centre  had  drawn  the  gold  from  the  sides,  thus  permitting  the  access  of  fluids 
and  ultimately  decaying  the  tooth  around  the  filling. 


278  MANNER    OF    FORMING    THE  CAVITY. 

that  the  situation  and  extent  of  the  decay  is  such  as  to  render  it 
impossible  to  make  the  cavity  so  large  at  the  bottom  as  at  the 
orifice ;  when  this  is  the  case,  several  pits  or  circular  grooves 
should  be  cut  in  the  inner  walls,  for  the.  purpose  of  obtaining  as 
much  security  for  the  filling  as  possible  ;  being  careful  to  make 
these  in  the  dentine,  rather  than  in  the  enamel,  which  is  so  much 
more  brittle.  By  proper  attention  to  this  precaution,  a  filling 
may  be  so  inserted,  in  this  difficult  class  of  cases,  as  to  prevent 
it  from  coming  out. 

As  a  general  rule  it  is  easier  to  form  a  cavity  in  the  grinding 
surface  of  a  molar  or  bicuspid,  than  in  any  other  position ; 
though  it  sometimes  happens,  that  even  here,  it  is  attended  with 
difficulty,  and  especially  when  the  decay,  commencing  in  the 
centre,  follows  the  several  depressions  which  run  out  from  it.  In 
such  cases  the  edges  bordering  on  and  covering  the  affected 
parts,  Avhich  are  often  thick  and  very  hard,  should  be  cut  away, 
together  with  the  subjacent  decayed  dentine ;  the  radiating  de- 
pressions should  open  fully  into  the  central  cavity,  and  be  made 
sufficiently  wide  and  deep  to  admit  of  being  filled  to  their  ex- 
tremities in  the  most  perfect  and  substantial  manner.  The  sur- 
face of  a  filling  occupying  a  cavity  of  this  kind  presents  a  sort 
of  stellated  appearance.  When  two  or  more  decayed  places  arc 
separated  only  by  very  thin  walls  of  tooth  substance,  these  should 
be  cut  away  and  a  cavity  formed  large  enough  to  include  all  the 
diseased  points ;  as  one  large  filling  will  secure  the  preservation 
of  the  tooth  more  effiectually  than  by  filling  each  cavity  sepa- 
rately. 

Sharp  angles  should  be  avoided,  as  far  as  possible,  in  the  outline 
of  the  orifice  of  the  cavity,  because  of  the  extreme  difficulty  of 
filling  them  compactly.  The  orifice  must  also  have  a  firm  de- 
cided margin ;  with  no  thin  projecting  edges  of  enamel  on  the 
one  hand ;  with  no  countersunk  depressions  on  the  other.  In 
the  first  case  the  thin  enamel  is  apt  to  break  off"  either  during 
the  operation  or  subsequently ;  in  the  second  case  the  thin  scale 
on  the  edge  of  such  fillings  breaks  away  in  the  course  of  time ; 
in  both  cases  the  filling  fails  perfectly  to  answer  its  purpose  in 
the  preservation  of  the  tooth. 

Before  a  cavity  can  be  prepared  in  the  approximal  surface  of 
a  tooth,  it  is  usually  necessary  to  separate  it  from  the  adjoining 


MANNER    OF   FORMING    THE  CAVITY.  279 

one.  This  may  be  done  either  with  a  file,  or  by  the  pressure  of 
some  interposed  elastic  substance.  Each  of  these  methods  has 
its  advantages.  When  caries  has  extended  over  nearly  the  whole 
of  the  approximal  surface,  so  that  after  the  removal  of  the 
diseased  part,  the  orifice  of  the  cavity  will  be  surrounded  by  a 
thin,  brittle  and  irregular  wall,  the  former  is  the  preferable 
method ;  especially  in  individuals  having  a  decided  scorbutic 
tendency,  or  who  have  sufiered  from  the  use  of  mercurial  medi- 
cines or  syphilitic  disease,  and  in  aged  persons.  But  when  the 
caries  has  spread  over  only  a  small  portion  of  the  surface  of  the 
tooth,  and  is  surrounded  by  sound,  healthy  enamel,  the  latter 
method  should  be  adopted ;  especially  in  individuals  in  whom 
there  is  no  manifest  tendency  to  inflammation  or  sponginess  of 
the  gums,  and  in  young  subjects.  The  manner  of  separating 
teeth  with  a  file,  has  been  already  described;  it  will  only  be 
necessary,  therefore,  in  this  place,  to  offer  a  few  remarks  on 
separating  by  pressure,  which  was  first  adopted  by  Dr.  Eleazar 
Parmly. 

The  following  are  its  advantages,  where  it  can  be  resorted  to 
with  safety :  after  the  removal  of  the  pressure,  the  teeth  almost 
immediately  come  together,  leaving  no  space  to  injure  their 
beauty ;  what  is  of  still  greater  importance,  the  dentine  around 
the  external  surface  of  the  filling  is  not  exposed  to  the  action  of 
the  secretions  of  the  mouth,  or  other  agents  capable  of  exerting 
upon  it  a  deleterious  action.  On  the  other  hand,  some  are  of 
opinion,  that  when  the  teeth  come  together  again  a  lodgment  is 
afforded  to  corrosive  agents,  upon  the  presence  of  which  the 
disease  was,  in  the  first  instance,  produced,  and  which  would 
soon  cause  a  recurrence  of  it.  In  replying  to  this  objection,  it 
is  only  necessary  to  observe,  that  the  parts  of  teeth  first  attacked 
by  caries,  were  the  points  in  contact  with  each  other,  where  the 
enamel  may  be  supposed  to  have  sustained  some  injury  by 
pressure,  thus  rendering  them  more  vulnerable  at  these  points  to 
the  action  of  the  causes  that  produced  the  disease.  By  properly 
replacing  the  diseased  parts  with  gold,  the  external  surfaces  of 
the  fillings  will  be  the  only  parts  that  come  in  contact  with  each 
other  -f  and  if  of  gold,  will  not  be  liable  to  injury  from  the  above 
mentioned  mechanical  causes.  The  enamel  around  the  fillings, 
if  proper  attention  to  cleanliness  be  observed,  is  not  so  liable  to 


280  MANNER    OF   FORMING   THE  CAVITY. 

be  acted  on  by  chemical  agents  as  the  dentine  ■which  the  file 
would  expose. 

But  teeth  cannot  always  with  impunity  be  separated  by  pres- 
sure ;  it  can  only  be  done  with  safety  in  certain  cases.  As  a 
general  rule,  the  writer  is  of  the  opinion  that  it  ought  not  to  be 
attempted  after  the  thirtieth  or  fortieth  year  of  age,  though  it 
may  sometimes  be  done  with  safety  at  even  a  later  period.  The 
diseased  action,  excited  for  the  time,  in  the  sockets  of  the  teeth, 
does  not  so  readily  subside,  at  a  later  age ;  and  it  has  in  some 
instances,  been  known  to  result  in  the  loosening  and  ultimate 
loss  of  the  organs.  In  one  case  which  came  under  the  observa- 
tion of  the  author,  the  inflammation  extended  to  the  lining  mem- 
branes of  the  pulp,  causing  their  disorganization,  and  the  conse- 
quent death  of  the  tooth. 

The  pressure  ought  never  to  be  too  actively  exerted ;  it  should 
be  gradual  and  constant.  From  four  to  twelve  days  are  usually  re- 
quired for  the  separation  of  two  teeth  sufficiently  for  the  removal 
of  the  decayed  part  and  the  introduction  of  a  filling.  After  they 
have  been  separated  in  this  way,  they  should  be  kept  apart, 
without  any  increase  of  pressure,  until  the  soreness  in  the  sockets 
shall  have  subsided,  before  any  farther  steps  are  taken  in  the 
operation.  Only  two  teeth  should  be  separated  in  the  front  part 
of  the  mouth,  in  the  same  jaw,  at  the  same  time. 

The  pressure  is  usually  made  by  introducing,  between  the 
croAvns  of  two  teeth,  a  thin  wedge  of  soft  wood,  a  piece  of  gum- 
elastic,  tape,  or  a  little  raw  cotton,  replacing  it  every  day  or  two 
with  a  thicker  piece.  The  writer  prefers  gum-elastic  to  any  other 
substance  he  has  employed  for  the  purpose ;  but  the  object  may 
be  readily  attained  with  other  substances. 

But  whether  the  teeth  be  separated  with  a  file  or  by  pressure, 
the  space  should  be  sufficiently  wide  to  enable  the  dentist  to 
operate  with  ease  ;  otherwise,  it  will  be  impossible  to  remove  the 
caries  and  fill  the  teeth  in  a  proper  manner. 

Dr.  ^Nlaynard  prefers  in  many  cases  of  front  approximal  fill- 
ings to  cut  away  the  inner  angles  of  the  tooth,  thus  avoiding  the 
injury  to  the  external  appearance  of  tlie  tooth  caused  by  the  file. 
Upon  completion  of  the  operation  the  surface  thus  cut  is  per- 
fectly polished,  and  so  shaped  as  to  be  kept  readily  cleansed 
with  the  brush  or  with  floss  silk. 


INSTRUMENTS   FOR    INTRODUCING   GOLD    FOIL.  281 

After  every  particle  of  decomposed  dentine  has  been  removed, 
the  cavity  should  be  thoroughly  cleansed  before  the  filling  is  in- 
troduced. This  may  be  done  by  first  injecting  tepid  water  into 
it  with  a  properly  constructed  syringe,  and  afterward  wiping  it 
dry  with  a  small  lock  of  raw  cotton  fixed  upon  the  point  of  a 
probe  or  excavator ;  or,  the  cavity  may,  in  the  first  place,  be 
wiped  with  a  little  raw  cotton  moistened  with  water,  and  after- 
ward with  dry  cotton.  Some  recommend  tissue  paper  for  dry- 
ing the  cavity,  for  the  reason  that  it  absorbs  moisture  more 
readily  than  cotton.  The  latter,  however,  is  the  most  conveni- 
ent, and  is  equally  as  good  as  the  former.  Its  absorbing  quali- 
ties may  be  increased  by  boiling  it  for  fifteen  or  twenty  minutes 
in  a  tolerably  strong  alkaline  solution  ;  this  done,  it  should  be 
thoroughly  washed  and  dried  before  using.  Several  materials 
have  been  of  late  years  used  in  drying  cavities.  Bibulous  paper, 
made  expressly  for  the  purpose,  and  having  a  very  loose  absor- 
bent texture.  Prepared  flax,  fine  and  white,  with  a  long  absor- 
bent fibre.  Cotton  from  which  the  natural  oil  has  been  removed 
by  saturation  in  ether.  It  is  desirable  that  the  cavity  should 
be  perfectly  dry  before  the  filling  is  introduced. 

INSTRUxMENTS  FOR   INTRODUCING  GOLD  FOIL. 

For  introducing  and  consolidating  the  gold,  a  number  of  in- 
struments are  required,  which  should  be  sufficiently  strong  to 
resist  any  amount  of  pressure  the  dentist  can  safely  exert  in  the 
operation.  They  should  have  round  or  octagonal  handles,  large 
enough  to  prevent  the  liability  of  being  broken,  and  to  enable 
liim  to  grasp  them  firmly.  Their  points  should  vary  in  size, 
though  none  should  be  very  large.  Several  should  be  straight, 
but  for  the  most  part,  they  require  to  be  curved — some  very 
slightly,  others  forming  with  the  shaft  of  the  instrument  an  an- 
gle of  ninety  degrees. 

Plugging  instruments  as  received  from  the  instrument  makers 
have  usually  a  temper  which  will  not  permit  them  to  be  bent. 
It  will  add  we  think  greatly  to  the  value  of  the  instrument,  if  the 
practice  of  Dr.  Maynard  were  more  generally  adopted.  He  gives 
to  the  extreme  point  a  hard  temper  (straw  color)  to  prevent  it 
from  wearing ;  for  a  little  distance,  say  one  to  three  quarters  of 
19 


282  INSTRUMENTS   FOR    INTRODUCING    GOLD    FOIL. 

an  inch,  a  spring  temper  is  given  (purple  or  blue  color)  to  insure 
strength  when  the  shape  is  delicate ;  the  rest  of  the  instrument 
is  left  soft,  so  as  to  admit  of  being  bent  (with  pliers)  in  the  di- 
rection best  suited  for  that  particular  point  in  any  given  opera- 
tion. 

Most  of  them  should  have  a  slim  wedge-shape  :  some,  however, 
both  of  the  straight  and  curved  instruments,  should  have  blunt 
serrated  points,  and  a  few  should  have  highly  polished  oval 
points,  for  finishing  the  surface  of  fillings.  Formerly  most  den- 
tists employed  for  introducing  and  consolidating  the  gold,  simple 
blunt-pointed  pluggers ;  but  it  is  impossible  with  such  instru- 
ments to  make  a  filling  as  firm  and  solid  as  it  should  be  for  the 
perfect  preservation  of  a  tooth,  especially  if  the  cavity  is  large. 
From  one-fourth  to  one-half  more  gold  can  be  introduced  into  a 
tolerably  large  cavity,  with  a  wedge-pointed  than  with  a  blunt- 
pointed  instrument. 

The  sides  of  the  wedge-pointed  pluggers  should  be  left  a  little 
rough,  for  the  purpose  of  preventing  them  from  cutting  the  gold, 
and  there  should  be  two  or  three  small  notches  filed  across  their 
edges.  When  thus  prepared,  the  gold  can  be  more  perfectly 
controlled  and  more  readily  conveyed  to  the  bottom  of  the  cavity 
than  with  smoother-edged  instruments.  The  blunt-pointed  in- 
struments, or  those  used  for  condensino-  the  extrudino;  extremities 
of  the  folds  of  gold,  should,  as  before  stated,  have  serrated  points, 
that  the  surface  of  the  metal  may  be  thoroughly  consolidated. 

This  general  description  will  serve  to  convey  a  tolerably  cor- 
rect idea  of  the  kind  of  instruments  required  for  the  operation ; 
but  no  two  dentists  have  their  filling  instruments  precisely 
alike  ;  each  has  them  constructed  in  such  a  way  as  he  thinks  will 
enable  him  to  apply  them  most  easily  and  eflficiently  to  the  vari- 
ous parts  of  a  tooth  which  may  require  filling.  In  the  chapter 
on  filling  individual  cavities  in  teeth,  cuts  of  most  of  the  instru- 
ments employed  in  the  operation  will  be  found. 

Points  of  somewhat  different  construction  are  required  for  fill- 
ing teeth  with  crystalline  or  sponge  gold,  and  with  adhesive  foil ; 
these  will  be  described  in  their  respective  places. 


INTRODUCING   AND    CONSOLIDATING    GOLD    FOIL.  283 


MANNER  OF  INTRODUCING  AND   CONSOLIDATING  GOLD  FOIL 
AND  FINISHING  THE  SURFACE  OF  THE  FILLING. 

The  operator,  being  provided  with  the  necessary  instruments, 
should  cut  his  gold  with  a  pair  of  scissors,  into  strips  from  half 
an  inch  to  an  inch  wide.  Each  of  these  should  be  loosely  rolled 
or  folded  together  lengthwise,  and  after  the  cavity  has  been  pro- 
perly cleansed  and  dried,  the  end  of  one  should  be  introduced 
and  carried  to  the  bottom  of  the  cavity,  with  a  straight  or  curved 
wedge-pointed  instrument ;  the  roll  on  the  outside  should  then  be 
folded  on  the  part  first  inserted.  The  folding  should  be  com- 
menced on  one  side  of  the  cavity,  and  the  inner  end  of  each  fold 
taken  to  the  bottom,  the  outer  extending  nearly  a  twelfth  or  an 
eighth  of  an  inch  on  the  outside  of  the  orifice ;  thus,  fold  after 
fold  is  introduced,  until  no  more  can,  in  this  manner,  be  forced 
into  the  cavity.  Having  proceeded  thus  far  with  the  operation, 
the  instrument  should  be  forced  through  the  centre  of  the  filling, 
and  the  gold  firmly  pressed  against  the  walls  of  the  cavity.  The 
opening  thus  made  should  be  filled  in  the  manner  as  first  de- 
scribed, and  this  time  it  should  be  packed  in  as  tightly  as  possi- 
ble. This  done,  the  operator  should  endeavor  to  force  in  a  small 
wedge-pointed  instrument,  at  the  side,  or,  what  is  much  safer, 
the  centre  of  the  cavity,  until  he  has  tried  every  part  of  the  plug ; 
filling,  as  he  proceeds,  every  opening  which  he  makes,  and  exert- 
ing, in  the  packing  of  the  gold,  all  the  pressure  which  he  can 
apply,  without  endangering  the  tooth.  If  one  roll  or  fold  of 
gold  is  not  enough,  he  should  take  another  and  another,  until 
the  cavity  is  thoroughly  filled. 

The  advantage  to  be  derived  from  introducing  the  gold  in  this 
manner  is  obvious.  By  extending  the  folds  from  the  orifice  to 
the  bottom  of  the  cavity,  the  liability  of  the  gold  to  crumble  and 
come  out,  is  effectually  prevented ;  while,  by  introducing  it  with 
a  wedge-pointed  instrument,  it  may  be  carried  into  all  the  de- 
pressions of  the  walls  of  the  cavity,  and  rendered  altogether 
more  solid  than  it  could  otherwise  be  made.  The  pliancy  and 
adhesiveness  of  the  gold  may  be  increased  by  slightly  annealing 
in  the  flame  of  a  spirit  lamp,  after  it  has  been  made  into  rolls  or 
folds. 


284  INTRODUCING    AND    CONSOLIDATING    GOLD    FOIL. 

After  the  cavity  has  been  completely  filled,  every  portion  of 
the  projecting  part  of  the  gold  must  be  thoroughly  consolidated, 
either  with  a  small  blunt-pointed  instrument,  straight  or  curved 
as  may  be  most  convenient ;  or  if  the  filling  is  in  the  approximal 
side  of  a  tooth,  it  may  be  compressed  with  the  angle  of  the  point 
of  the  plugger,  making  the  adjoining  organ  to  a  slight  extent  a 
kind  of  fulcrum  for  the  instrument.  After  the  filling  has  been 
thus  consolidated,  as  long  as  it  can  be  made  to  yield  in  the  least 
to  the  pressure  of  the  instrument,  the  protruding  parts  may  be 
scraped  or  filed  off",  down  to  the  tooth,  so  as  to  form  a  smooth, 
uniform,  gently  swelling  or  perfectly  flat  surface.  If  in  this 
part  of  the  operation  any  portion  of  the  gold  should  crumble  or 
be  dislodged,  which  it  will  not  do  if  it  has  been  properly  intro- 
duced and  consolidated,  the  injury  may  be  repaired  by  making 
in  the  part  of  the  plug,  where  it  has  occurred,  an  opening,  and 
filling  it,  or  by  the  removal  of  the  whole  of  the  filling  and  the 
introduction  of  another.  Every  part  of  the  surface  of  the  filling 
should  be  uniform  and  free  from  the  slightest  indentations  which 
may  afford  lodgment  to  clammy  mucus  or  extraneous  matter  of 
any  sort.  This  is  a  point  which  should  never  be  lost  sight  of, 
for,  however  excellent  the  filling  may  be  in  other  respects,  if  the 
surface  is  not  smooth,  uniform,  and  flush  with  the  orifice  of  the 
cavity,  the  object  intended  to  be  accomplished  by  it  will  be  par- 
tially if  not  wholly  defeated.  If  any  portions  of  the  gold  have 
been  forced  over  the  edge  of  the  orifice  of  the  cavity,  they  should 
be  carefully  removed,  either  with  a  file  or  sharp-pointed  cutting 
instrument  suited  to  the  purpose.  This  precaution  should  never 
be  neglected,  especially  when  the  filling  is  in  the  approximal 
surface  of  a  tooth,  where  a  portion  of  the  gold  is  very  liable  to 
be  forced  up  or  down  upon  the  neck,  and  under  the  gum. 

After  having  prepared  the  surface  of  the  filling  in  the  manner 
as  here  described,  it  may  be  rubbed  with  finely  powdered  pumice 
stone,  or  with  a  small  stick  or  slab  of  Arkansas  oil-stone,  until 
all  the  file  scratches  or  other  asperities  are  removed.  If  the 
filling  is  in  the  grinding,  buccal  or  palatine  surface  of  a  molar 
or  bicuspid,  a  long  prece  of  the  stone,  having  a  small  triangular 
and  slightly  oval  point,  may  be  used ;  if  powdered  pumice  stone 
be  employed,  it  may  be  used  on  the  point  of  a  similarly  shaped 
piece  of  soft  wood,  previously  moistened  in  water.  For  a  filling 
in  the  approximal  surface  of  a  tooth,  the  oil-stone  may  be  shaped 


INTRODUCING   AND   CONSOLIDATING    GOLD    FOIL.  285 

like  a  pinion  file ;  it  should  be  frequently  dipped  in  water,  and 
when  its  pores  become  filled  with  gold,  the  surface  may  be  ground 
off  by  rubbing  it  on  a  corundum  slab.  If  the  filling  is  finished 
with  pumice,  it  may  be  applied  with  floss  silk  or  tape  moistened 
with  water,  by  drawing  it  backward  and  forward  across  the 
surface  of  the  filling. 

After  all  the  asperities  have  been  cut  down,  the  surface  should 
be  washed  until  every  particle  of  grit  is  removed.  This  done,  it 
may  be  polished  with  a  suitable  burnisher,  dipping  it  in  water 
from  time  to  time,  having  a  small  quantity  of  pure  castile  soap 
dissolved  in  it,  until  the  filling  is  rendered  as  brilliant  as  a 
mirror.  Having  proceeded  thus  far,  it  may  be  again  washed, 
and  the  operation  completed  by  rubbing  it  from  three  to  six 
minutes  with  dry  floss  silk. 

When  the  caries  has  penetrated  nearly  to  the  pulp  cavity,  the 
presence  of  a  gold  or  any  other  metallic  filling  is  sometimes  pro- 
ductive of  considerable  pain  and  irritation,  especially  when  hot 
or  cold  fluids  are  taken  into  the  mouth,  or  during  the  inspiration 
of  cold  air.  In  some  cases,  inflammation  and  suppuration  of  the 
lining  membrane  and  pulp  supervenes.  To  prevent  these  dis- 
agreeable results,  a  variety  of  means  have  been  proposed.  Dr. 
Solyman  Brown  recommends  placing  asbestos,  this  being  a  non- 
conductor of  caloric,  on  the  bottom  of  the  cavity,  previously  to 
the  introduction  of  the  gold.  Others  recommend  placing  a  thin 
piece  of  cork,  and  others,  again,  oiled  silk,  between  the  filling 
and  the  bottom  of  the  cavity.  The  author  prefers  a  thin  layer 
oi  gutta  'percha.  This  is  less  destructible  than  either  of  the  two 
last  named  articles,  and  can  be  more  conveniently  and  perfectly 
applied.  It  may  be  used  in  the  form  of  a  thick  solution,  pre- 
pared with  chloroform,  or  a  layer  of  thin  gutta  percha  cloth  may 
be  placed  at  once  in  the  bottom  of  the  cavity.  When  the  solu- 
tion is  used,  a  drop  may  be  placed  in  the  cavity,  and  a  sufiicient 
time  allowed  for  the  choloroform  to  evaporate,  before  introduc- 
ing the  filling.  A  thin  layer  of  "Hill's  stopping,"  of  which 
gutta  percha  forms  the  principal  ingredient,  may  be  used  with 
equal  advantage. 

The  time  required  by  an  expert  operator  to  fill  a  tooth  well, 
may  be  said  to  vary  from  thirty  minutes  to  two  hours  and  a  half, 
according  to  the  size,  shape,  and  situation  of  the  cavity,  and  in 
some  cases  a  much  longer  time  will  be  required.     The  author 


286  INTRODUCING    AND    CONSOLIDATING    GOLD   FOIL. 

has  found  it  necessary  in  filling  some  cavities,  especially  when 
the  restoration  of  a  large  portion  of  the  crown  was  called  for,  to 
bestow  as  many  as  six  hours'  constant  labor  upon  the  operation. 
Less  time  and  skill  are  usually  required  to  fill  a  cavity  in  the 
grinding  than  in  the  approximal  surface  of  a  tooth ;  but  the 
operation  in  either  place,  to  be  beneficial  to  the  patient,  must  be 
performed  in  the  most  thorough  manner.  The  dentist  who  does 
not  feel  the  importance  of  making  all  his  operations  as  perfect 
as  possible,  should  never  be  entrusted  with  the  management  of 
these  important  organs.  Want  of  attention  to  two  points  in  the 
consolidation  of  a  filling,  often  causes  the  ultimate  failure  of 
operations  in  all  other  respects  well  performed.  First,  by  not 
making  sufficient  lateral  compression  whilst  introducing  the  gold, 
the  surface  is  apt  to  be  more  solid  than  the  interior.  Conse- 
quently the  filling  may  drop  out  for  want  of  a  firm  contact 
against  the  sides ;  or  if  retained,  it  is  apt  on  grinding  surfaces 
to  be  pressed  inward,  leaving  a  space  around  the  orifice  for  the 
penetration  of  fluids.  Second,  want  of  care  in  condensing  around 
the  edges  of  the  filling,  will,  by  the  crumbling  away  or  scaling 
off  of  portions  of  the  gold,  expose  the  edges  of  the  cavity  to  decay. 

In  every  part  of  the  operation,  the  dentist  should  so  guard 
his  instruments  as  to  prevent  them  from  slipping  ;  which  he  will 
usually  be  better  able  to  do  by  standing  a  little  to  the  right  and 
behind  his  patient  than  in  any  other  position.  In  filling  the 
lower  teeth  he  should  stand  several  inches  higher  than  while 
filling  the  upper,  and  for  this  purpose  he  should  have  a  stool,  or 
movable  platform  on  which  to  stand.  When  it  can  be  done,  he 
should  grasp  the  tooth  with  the  thumb  and  fore-finger  of  his  left 
hand,  not  only  to  prevent  it  from  being  moved  by  the  pressure 
he  applies,  but  also  to  catch  the  point  of  the  instrument  in  case 
it  should  slip ;  if  he  is  always  careful  to  press  in  a  direction  to- 
wards the  orifice  of  the  cavity,  this  need  not  happen ;  neverthe- 
less, he  should  always  take  the  precaution  to  guard  against  pos- 
sible accident.  When  he  cannot  shield  the  mouth  with  the 
thumb  and  finger  of  his  left  hand,  he  should  let  the  thumb  or 
one  of  the  fingers  of  his  right  rest  either  upon  the  tooth  he  is 
operating  on,  or  upon  some  other. 

For  the  special  application  and  modification  of  these  general 
directions  to  the  filling  of  individual  cavities  in  teeth,  the  reader 
is  referred  to  the  next  chapter. 


CHAPTER     FOURTH. 
FILLING  INDIVIDUAL  CAVITIES  IN  TEETH. 

To  describe  the  method  of  filling  each  individual  cavity  in 
every  locality  in  which  a  tooth  is  liable  to  be  attacked  by  caries, 
would  be  unnecessarily  tedious.  But,  as  this  is  one  of  the  most 
important,  and,  at  the  same  time,  one  of  the  most  difficult  opera- 
tions in  dental  surgery,  it  may  he  well  to  enter  a  little  more  into 
detail  upon  the  subject,  than  we  have  as  yet  done.  In  doing 
this,  the  writer  will  confine  himself,  for  the  most  part,  to  the 
manner  of  filling  a  cavity  in  each  of  the  following  localities, 
which  are  the  parts  of  teeth  most  liable  to  caries. 

First. — In  the  approximal  and  labial  surfaces  of  the  superior 
incisors  and  cuspids,  and  the  palatine  surfaces  of  the  incisors — 
the  anterior  surfaces  of  the  cuspids  and  the  posterior  surfaces  of 
cuspids  and  incisors  being  rarely  attacked  by  caries. 

Second. — In  the  grinding,  approximal,  buccal  and  palatine 
surfaces  of  the  molars  and  bicuspids  of  the  upper  jaw. 

Third. — In  the  approximal  surfaces  of  the  inferior  incisors 
and  cuspids. 

Fourth. — In  the  grinding,  approximal,  and  buccal  surfaces  of 
the  molars  and  bicuspids  of  the  lower  jaw. 

Other  parts  of  the  teeth  sometimes  become  the  seat  of  caries, 
but  the  foregoing  are  the  localities  most  liable  to  be  attacked  by 
the  disease. 

FILLING  THE  SUPERIOR  INCISORS  AND  CUSPIDS. 

In  describing  the  manner  of  introducing  a  filling  in  one  of  the 
first  named  teeth,  we  shall  commence  with  the  right  approximal 
surface  of  the  left  central  incisor.  The  directions  we  propose 
giving  for  the  performance  of  the  operation  here,  will  be  appli- 
cable with  a  few  exceptions  to  the  same  surface,  on  all  the  upper 
mcisors.     As  a  general  rule  the  gold  should  be  introduced  from 


288  FILLING    SUPERIOR   INCISORS    AND    CUSPIDS. 

behind  the  teeth  forward  and  upward,  and  for  the  following 
reasons  :  1.  When  the  aperture  between  the  teeth  has  been 
formed  with  a  file,  it  should,  when  the  circumstances  of  the  case 
will  permit,  and  for  reasons  stated  in  another  place,  be  made 
wider  behind  than  before ;  consequently,  the  diseased  part  can  be 
most  easily  approached  from  this  direction.  2.  The  gold,  in  the 
majority  of  cases,  can  be  more  conveniently  introduced  from  the 
palatine  side,  and  the  force  required  for  condensing  it  can  be 
more  advantageously  applied. 

The  exceptions  to  the  above  rule  are,  when  the  approximal 
side  of  the  tooth  is  turned  slightly  forward  toward  the  lip,  and 
when  the  caries  is  situated  nearer  the  labial  than  the  palatine 
angle ;  also,  when  the  teeth,  instead  of  occupying  a  vertical 
position  in  the  alveolar  border,  or  projecting  slightly  as  they 
usually  do,  incline  backward  toward  the  roof  of  the  .mouth.  It 
sometimes  happens,  too,  when  they  are  separated  by  pressure, 
that  the  diseased  part  can  be  most  conveniently  reached  from 
before. 

The  instrument  which  the  writer  has  found  best  adapted  for 
the  introduction  of  the  gold  into  a  cavity  in  the  right  approximal 
surface  of  an  incisor  or  cuspid  tooth,  is  represented  in  Fig.  94. 
The  width  and  length,  as  well  as  the  curvature  or  angle  of  the 
point,  should  vary  according  to  the  size  of  the  cavity  and  the 
width  of  the  space  between  the  teeth. 

Fig.  94. 


The  stem  of  the  instrument  as  well  as  the  shank  should  be 
strong  enough  to  sustain  any  amount  of  pressure  which  it  may 
be  necessary  to  apply  in  forcing  the  folds  of  gold  tightly  against 
each  other.  The  point  should  be  wedge-shaped,  and  the  extre- 
mity serrated. 

The  ornamental  beading  and  collar  are  objected  to  by  some 

operators,  as  apt  to 
wound  the  mouth.  The 
shaft,  ferule  and  handle 
may  be  made  continuous- 
ly tapering,  as  in  Fig.  95. 


FILLING    SUPERIOR    INCISORS    AND    CUSPIDS.  289 

The  decay  having  been  removed,  the  cavity,  properly  shaped, 
cleansed  and  dried,  is  ready  for  the  reception  of  the  gold. 
The  patient  should  be  seated  in  a  chair  sufficiently  high  to  bring 
the  head  on  a  level  with  the  breast  of  the  operator,  and  resting 
on  the  head-piece  of  the  chair  with  the  face  upward.  The  ope- 
rator standing  upon  the  right  side,  should  support  the  patient's 
head  firmly  with  his  left  arm  during  the  operation,  while  with 
the  thumb  and  fore-finger  of  the  same  hand,  the  strip  or  roll  of 
gold  is  held,  and  one  end  placed  in  a  proper  position  to  be 
introduced  into  the  cavity.  The  middle  finger  of  the  same  hand 
ought  to  rest  on  the  end  of  a  tooth  to  the  left  of  the  one  on 
which  the  operation  is  being  performed,  while  with  the  little 
finger  the  lower  lip  may  be  gently  depressed. 

During  the  introduction  of  the  gold,  the  instrument  should  be 
held  (Fig.  96,)  in  the  right  hand  of  the  operator,  and  grasped 
with  sufficient  firmness  to  prevent  it  from  slipping  or  rotating. 

In  introducing  the  gold,  the  first  fold  should  be  applied  against 
the  upper  wall  of   the 

cavity,   that    the    pres-  ■^'^-  ^^• 

sure  may  always  be 
exerted  in  a  direction 
toward  the  extremity 
of  the  root,  applying 
each  additional  fold  as 
closely  to  the  preceding 
one  as  possible.  The 
folds  should,  also,  in 
their  introduction,  be  applied  as  closely  to  the  labial  and  palatine 
walls  of  the  cavity  as  possible,  but  always  directing  the  pressure, 
when  these  are  thin  and  brittle,  in  the  direction  of  the  axis  of 
the  root. 

When  the  lower  part  of  the  cavity  is  very  narrow,  as  is  often 
the  case,  especially  where  it  extends  nearly  to  the  labial  angle 
of  the  tooth,  it  is  often  necessary  to  change  the  instrument  for 
one  having  a  smaller  point. 

To  carry  a  fold  of  gold  to  the  bottom  of  a  cavity,  upon  the 
point  of  the  instrument,  without  breaking  or  cutting  it,  requires 
some  tact.  The  point  should  never  be  carried  directly  toward 
the  bottom :  on  entering  the  orifice,  it  should  be  inclined  toward 


290  FILLING   SUPERIOR   INCISORS   AND   CUSPIDS. 

the  wall  of  the  cavity  opposite  the  one  against  which  the  folds 
are  first  laid.  Equally  as  much  tact  is  required  to  prevent 
displacing  the  gold  before  a  sufficient  quantity  has  been  intro- 
duced to  procure  support  for  it  from  the  surrounding  walls: 
which  is  an  accident  particularly  apt  to  occur  Avith  young  prac- 
titioners, when  the  cavity  is  superficial  and  has  a  large  orifice. 
To  prevent  this,  the  folds  of  gold  should  be  long  enough  to 
project  some  distance  from  the  orifice,  that  they  may  receive 
support  from  the  adjoining  tooth,  and  from  the  thumb  and  fore- 
finger of  the  left  hand  of  the  operator,  until  the  operation  has 
reached  that  stage  when  sufficient  stability  shall  have  been 
obtained  from  the  walls  of  the  cavity. 

There  are  cases  in  which  an  instrument  like  the  one  repre- 
sented in  Fig.  97  can  be  very  advantageously  employed  in  the 

introduction  of   the  gold ;    but  in    the 
Fig.  97.  . 

' majority  of  cases  the  instrument  repre- 

tJ'""^    ""^^^^^^^     sented  in  Fig.  94  will  be  found  more 

convenient. 

After  having  filled  the  cavity  so  thoroughly  that  a  small 
wedge-pointed  instrument  cannot  be  made  to  penetrate  the  gold 
at  any  point,  the  extruding  portion  of  the  filling  should  be  con- 
solidated; beginning  with  the  portions  overlapping  the  lower 
part  of  the  tooth  and  the  edge  of  the  posterior  wall.  These 
should  be  carefully  and  firmly  pressed  toward  the  cavity,  with 
an  instrument  like  the  one  represented  in  Fig.  98.  This  done, 
it  may  be  firmly  applied  to  every  part  of  the  surface  of  the  filling, 
continuing  the  pressure  as  long  as  the  point  of  the  instrument 
can  be  made  to  indent  the  gold. 

When  the  space  between  the  teeth  is  very  narrow,  an  instru- 
ment shaped  as  in  Fig.  99  may  be  used.  The  operator  should 
be  provided  with  two  or  three  instruments  like  each  of  the  two 
last,  varying  in  the  size,  length  and  curvature  of  their  points. 

FtG.  98.  Fig.  99. 


During  the  process  of  consolidating  the  gold,  the  teeth  should 
be  firmly  grasped  between  the  thumb  and  fore-finger  of  the  left 
hand ;  this  prevents  it  from  being  pressed  too  forcibly  against 


FILLING   SUPERIOR   INCISORS   AND   CUSPIDS. 


291 


the  opposite  side  of  the  socket,  while,  at  the  same  time,  the  end 
of  the  fore-finger,  by  being  placed  above  the  instrument,  assists 
in  directing  its  point,  and  serves  to  keep  it  from  slipping. 
When  the  labial  and  palatine  walls  of  the  cavity  are  very  thin, 
great  care  is  necessary  to  prevent  fracturing  them,  in  introducing 
and  consolidating  the  gold.  The  consolidation  should  be  com- 
menced around  the  edges,  and  the  pressure  applied  toward  the 
centre  of  the  cavity. 

It  sometimes  happens  that  the  caries  extends  forward  to  the 
labial  angle  of  the  tooth,  and  upward,  at  the  same  time,  under 
the  edge  of  the  gum.  Great  difficulty  is  often  felt  in  thoroughly 
filling  this  portion  of  the  cavity,  and  it  cannot  always  be  done 
from  behind  the  tooth.  In  this  case,  after  having  filled  the 
cavity  in  the  manner  as  already  described,  the  operator  may, 
standing  on  the  left  side  of  the  patient,  and  with  an  instrument 
having  awedge-shaped  point,  (Fig.  100,) 
make  as  large  an  opening  as  possible  in 
the  gold.  This  done,  he  may  grasp  the 
left  lateral  incisor,  or  cuspid  tooth,  with 

the  thumb  and  middle  finger  of  his  left  hand,  elevating  the  upper 
lip  with  the  fore-finger  of  the  same ;  then,  with  the  instrument 
held  as  in  Fig.  101,  he  may  proceed  to  introduce  the  gold,  filling 

Fig.  101. 


Fig.  100. 


the  upper  part  of  the  opening  first.  After  introducing  fold 
after  fold,  until  it  is  completely  and  compactly  filled,  the  ex- 
truding portion  should  be  consolidated  with  a  similarly  shaped 
instrument,  having  a  round  serrated  point,  or  the  one  represented 
in  Fig.  99. 
The  size  of  the  roll  of  gold  must  be  varied  to  suit  the  size  of 


292  FILLING    SUPERIOR   INCISORS    AND    CUSPIDS. 

the  cavity,  though  it  should  sehlom  have  in  it  more  than  a  fourth 
of  a  leaf  of  No  4.  If  more  than  this  be  employed  at  one  time, 
it  "will  be  difficult  to  apply  the  folds  sufficiently  near  each  other. 

When  the  teeth  have  been  separated  by  pressure,  or  when  the 
aperture  is  as  wide  anteriorly  as  posteriorly,  the  gold  may  be 
introduced  from  either  side  as  is  most  convenient;  but,  when  in- 
troduced from  before,  it  may  be  done  in  the  manner  as  just  de- 
scribed, the  operator  standing  on  the  left  side  of  his  patient,  and 
using  such  instrument  as  he  finds  best  adapted  (Fig.  94  or  100). 
The  gold  having  been  introduced  and  condensed,  the  surface  of 
the  filling  is  to  be  finished  in  the  manner  already  described. 

The  method  of  filling  the  right  central  incisor  in  the  left  ap- 
proximal  surface  is  so  very  similar  to  that  of  filling  the  left  in 
the  right  side,  that  it  will  not  be  necessary  to  enter  so  minutely 
into  detail.  In  this  as  in  the  other  case,  the  gold,  as  a  general 
rule,  should  be  introduced  from  behind  the  tooth,  forward  and 
upward;  but  if  introduced  from  the  front,  the  operator  should 
still  stand  on  the  right  side  of  the  patient.  The  head  should 
have  the  same  elevation,  and  inclination  backward;  but  the  face 
should  be  turned  more  toward  the  operator  to  give  him  a  better 
view  of  the  cavity  in  the  tooth,  and  to  enable  him  to  reach  it 
more  readily  with  the  instrument. 

The  cavity  being  formed,  cleansed  and  dried,  the  operator 
may  proceed  to  introduce  the  gold  as  already  directed,  Avith  an 
instrument  like  the  one  represented  in  Fig.  94.     In  many  cases, 

Fig.  102. 


however,  he  will  require  one  having  a  somewhat  longer  point, 
and  curved  at  nearly  a  right-angle  with  the  stem.  The  instru- 
ment should  be  held  somewhat  differently  in  the  hand  (Fig.  102), 


FILLING    SUPERIOR   INCISORS    AND    CUSPIDS.  293 

and  grasped  firmly  with  the  thumb  and  fore  and  middle  fingers, 
so  as  to  prevent  it  from  rotating.  The  head  should  be  securely 
confined  with  the  left  arm,  the  upper  lip  raised  with  the  left 
thumb,  pressing  it  at  the  same  time  firmly  against  the  anterior 
surface  of  the  tooth.  The  middle  or  fore-finger  of  the  same 
hand  may  be  placed  against  the  gum  just  inside  the  tooth,  to 
direct  the  application  of  the  point  of  the  instrument,  prevent 
the  liability  of  its  slipping,  and  control  the  free  end  of  the  roll 
of  foil.  The  lower  lip  may  be  depressed  either  with  the  middle 
joint  of  this,  or  with  one  of  the  other  fingers. 

After  having  placed  one  end  of  the  gold  in  the  cavity,  fold 
after  fold  should  be  introduced  until  it  is  compactly  filled ;  except 
in  those  cases  where  the  lower  part  is  very  small,  when  a  smaller 
pointed  instrument  should  be  employed  for  the  completion  of  the 
operation ;  and  indeed  for  the  introduction  of  all  the  gold,  if  the 
cavity  is  not  larg^  or  the  aperture  between  the  teeth  very 
narrow. 

For  consolidating  the  extruding  gold,  the  instrument  repre- 
sented in  Fig.  98  will,  in  many  cases,  be  all  that  is  required. 
But  the  one  represented  in  Fig.  103  can  sometimes  be  used  very 

Fig.  103.  Fig.   104. 


advantageously;  and  the  one  in  Fig.  10-4  will  be  found  a  useful 
condenser  for  the  right,  as  well  as  the  left,  approximal  surface 
of  an  incisor,  or  cuspid  tooth;  and  both  the  last  mentioned  in- 
struments may  often  be  used  to  great  advantage  on  the  approxi- 
mal surfaces  of  other  teeth.  The  instruments  represented  in  the 
chapter  on  filling  teeth  with  crystalline  and  sponge  gold  (Fig. 
129),  may  also  be  advantageously  employed  in  consolidating  the 
ordinary  gold  in  the  approximal  surfaces  of  the  incisors  and 
other  teeth. 

In  completing  the  operation,  it  is  important  that  every  parti- 
cle of  gold  overlapping  the  orifice,  and  frequently  extending 
under  the  free  edge  of  the  gum,  should  be  removed  before  finish- 
ing the  surface  of  the  filling;  but  the  operator  ought,  at  the 
same  time,  to  avoid  as  much  as  possible  wounding  the  gum  and 
dental  periosteum.     As  the   cavity  frequently  extends  a  little 


294 


FILLING    SUPERIOR    INCISORS    AND    CUSPIDS. 


above  the  gum,  great  care  is  necessary  to  prevent  wounding  it ; 
indeed,  there  are  many  cases  in  which  it  cannot  be  avoided,  un- 
less the  point  of  the  gum  is  pressed  up  between  the  teeth,  by  the 
introduction  of  a  piece  of  raw  cotton,  or  gum  elastic,  a  day  or 
two  before  the  operation  of  filling  is  performed. 

In  filling  an  incisor,  or  cuspid  tooth,  on  the  labial  surface,  the 
operation  is  often  very  simple  and  easy;  but  there  are  many 
cases  in  which  it  is  both  difficult  and  tedious.  The  head  of  the 
patient  should  rest  with  the  face  upward,  as  already  described, 
and  sustained  in  the  same  way  with  the  left  arm  of  the  operator; 
while,  with  the  thumb  of  the  left  hand  placed  on  the  gum  above 
the  tooth,  the  upper  lip  should  be  elevated. 

The  fore-finger  should  be  pressed  firmly  against  the  palatine 
surface  of  the  tooth,  and  the  left  side  of  the  chin  gently  grasped 
with  the  other  three  fingers.  Then,  with 
an  instrument  (Fig.  105)  having  a  wedge- 
shaped  point,  grasped  with  the  right  hand, 
as  in  Fig.  102,  or  106,  the  operator  should 
proceed  to  introduce  the  gold,  standing  at 
the  right  side  of  the  patient,  with  the  thumb  of  the  right  hand 
resting  on  a  tooth  to  the  left  of  the  one  he  is  about  to  fill,  <^^ 
against  the  cheek.  He  should  commence  by  laying  the  first 
folds  against  the  walls  of  the  cavity  nearest  to  him,  and  thus 
introduce  fold  after  fold,  until  it  is  compactly  filled.     The  ex- 

FiG.   106. 


Fig.  105. 


■•,<l'/' 


truding  portion  may  be  consolidated  with  a  round  or  square- 
pointed  instrument,  or  with  a  straight-pointed  one  as  represented 
in  Fig.  107.  Great  care  is  necessary  to  prevent  the  instrument 
from  slipping  and  wounding  the  gums.     After  having  partially 


FILLING    SUPERIOR   INCISORS    AND    CUSPIDS.  295 

consolidated  the  gold,  the  overlapping  portion  must  be  firmly 

pressed  toward  the  centre  of  the  cavity, 
^  .  .  •"  Fig.  107. 

and  the  point  of  the  instrument  repeat- 
edly applied  to  every  part  of  the  surface 
of  the  filling,  until  it  can  no  longer  be 

made  to  yield  to  pressure.  This  done,  the  gold  may  be  filed 
down  to  the  level  of  the  tooth,  smoothed  "with  Arkansas  stone, 
and  burnished  or  polished. 

When  the  cavity  is  shallow  and  the  orifice  broad,  the  gold  as 
it  is  introduced  must  be  held  in  its  place  with  the  thumb  of  the 
left  hand,  until  a  sufficient  quantity  has  been  placed  in  the  cavity 
to  obtain  for  it  the  necessary  support  from  the  surrounding  walls. 
But  in  overcoming  difficulties  of  this  sort,  the  peculiar  circum- 
stances of  the  case  can  alone  suggest  the  proper  means  to  be 
employed  by  the  operator. 

The  decay  sometimes  extends  entirely  across  the  labial  sur- 
face of  the  tooth,  leaving,  after  its  removal,  a  horizontal  groove 
open  at  both  ends.  In  this  case  the  walls  should  be  made 
rough,  wider  at  the  bottom  than  at  the  opening,  and  the  opera- 
tion of  filling  commenced  at  one  end,  by  applying  the  folds  of 
foil,  alternately  against  the  upper  and  lower  wall,  and  consoli- 
dating them  so  thoroughly  as  to  prevent  the  liability  of  their 
being  displaced  during  any  subsequent  part  of  the  operation. 
Successive  folds  are  introduced  in  the  same  manner,  each  in  close 
contact  with  the  preceding  series,  until  the  groove  is  completely 
filled,  applying  the  pressure  during  the  whole  of  the  operation 
against  the  two  walls.  In  condensing  the  extruding  gold,  the 
operator  should  commence,  first  at  one  end  of  the  groove,  then 
at  the  other,  and  afterwards  consolidate  the  whole  surface  of  the 
filling.  In  finishing  the  operation,  the  same  precaution,  with 
regard  to  wounding  the  gum  and  dental  periosteum,  should  be 
observed  here  as  recommended  for  the  approximal  surface  of  the 
tooth. 

Although  it  rarely  happens  that  the  palatine  surfaces  of  the 
upper  incisors  are  attacked  by  caries,  yet  the  disease  does  some- 
times develop  itself  there,  in  the  indentations  occasionally  found 
a  little  below  the  free  edge  of  the  gum.  The  removal  of  the 
diseased  part,  the  formation  of  a  cavity,  and  the  introduction  of 
a  filling,  can,  in  the  majority  of  cases,  be  more  easily  accom- 
plished in  this,  than  in  any  other  part  of  an  incisor  tooth. 


296  FILLING    SUPERIOR    MOLARS    AND    BICUSPIDS. 

The  cavity  being  properly  prepared  for  filling,  the  head 
should  be  placed  as  before  directed,  except  that  the  chin  may  be 
a  little  more  elevated,  to  enable  the  operator  to  obtain  a  more 
convenient  view  of  the  locality  of  his  operation ;  the  thumb  of 
the  left  hand  may  be  placed  on  the  labial  surface  of  the  tooth  ; 
and  the  fore-finger  on  the  gum  immediately  above  the  palatine 
surface.  He  should  now,  with  a  wedge-pointed  instrument, 
shaped  as  in  Fig.  108,  proceed  to  introduce  the  gold,  applying 

Fig.  108.  Fig.  109.  . 


the  first  fold  against  the  palatine  wall  or  the  palato-approximal 
angle  of  the  cavity,  as  may  be  most  convenient.  Having  filled 
the  cavity,  the  extruding  gold  may  be  condensed  with  an  instru- 
ment like  the  one  represented  in  Fig.  109. 

Sometimes  straight  instruments,  and  at  other  times  instru- 
ments curved  at  the  points  more  than  those  represented  in  Figs. 
108  and  109,  can  be  more  conveniently  employed ;  depending 
altogether  upon  the  size  of  the  mouth  and  the  forward  or  back- 
ward deviation  of  the  teeth  from  a  vertical  position.  This  is  a 
matter,  therefore,  which  the  judgment  of  the  operator  must  de- 
termine. 

FILLING  THE  SUPERIOR  MOLARS  AND  BICUSPIDS, 

In  describing  the  manner  of  filling  a  cavity  in  each  of  the 
principal  localities  liable  to  be  attacked  by  caries,  in  the  above 
mentioned  teeth,  the  writer  will  begin  with  the  grinding  surface 
of  the  first  molar  on  the  right  side.  The  directions  given  for 
filling  a  cavity  here,  will,  with  a  few  exceptions,  be  applicable 
to  the  introduction  of  a  filling  in  the  grinding  surface  of  any  of 
the  upper  molars  or  bicuspids. 

When  the  cavity  is  very  deep,  and  its  circumference  not  large, 
it  is  difficult,  if  not  impossible,  to  make  a  filling  sufficiently  firm 
and  solid  in  every  part  by  the  introduction  of  folds  of  gold  long 
enough  to  extend  from  the  bottom  to  the  orifice.  The  operation, 
therefore,  should  be  divided  into  two  parts :  two-thirds  of  the 
cavity  should  be  first  thoroughly  filled  with  vertical  folds,  and 
afterward  the  remaining  third  in  the  same  manner. 


FILLING    SUPERIOR    MOLARS    AND    BICUSPIDS.  297 

In  filling  a  molar  or  bicuspid  on  any  of  its  surfaces,  the  head 
of  the  patient  should,  for  the  most  part,  occupy  very  nearly  the 
same  position,  and  have  the  same  elevation  as  required  for  an 
operation  on  an  incisor  or  cuspid.  The  cavity  being  prepared 
for  the  filling,  and  one  end  of  the  roll  of  foil  placed  in  it,  the 
tooth  may  be  grasped  with  the  thumb  and  fore-finger  of  the  left 
hand  of  the  operator — the  former  placed  on  the  buccal  surface 
in  such  a  manner  as  to  press  back  the  commissure  of  the  lips, 
and  the  latter  on  the  palatine  surface  ;  then  fold  after  fold  may 
be  introduced  and  forcibly  pressed  against  the  posterior  wall 
until  the  cavity  is  filled.  For  this  purpose  an  instrument  may 
be  used  like  the  one  represented  in  Figs.  105  or  107.  If  the  former 
is  used,  it  is  to  be  held  as  shown  in  Fig.  102.  The  extruding 
portion  should  then  be  condensed  with  a  straight  instrument  as 
in  Fig,  107,  or  curved  pluggers,  Figs.  109  or  110,  as  may  be  most 
convenient. 

As  a  general  rule,  filling  a  cavity  in  the  grinding  surface  of 
an  upper  molar  or  bicuspid  is  an  exceedingly  simple  operation, 
requiring  less  skill  than  the  introduction  of  a  plug  in  any  other 
locality  in  these  teeth  ;  but  there  are  cases  in  which  it  is  rendered 
very  difiicult ;  as  for  example,  when  there  are  one  or  more  fis- 
sures or  carious  depressions  radiating  from  the  main  cavity. 
After  the  caries  has  been  removed,  which  is  often  a  very  tedious 
operation,  it  requires  considerable  time  and  skill  to  fill  these 
thoroughly.  When  it  is  not  properly  done,  as  is  too  often  the 
case,  a  recurrence  of  the  disease  will  soon  take  place,  and  thus 
defeat  the  object  for  which  the  operation  was  performed. 

The  intl'oduction  of  a  filling  in  the  grinding  surface  of  the 
second  or  third  molar  of  a  person  having 
a  very  small  mouth,  is  sometimes  attend- 
ed with  great  difiiculty ;  in  some  cases  it 
can  only  be  done  with  an  instrument 
having  a  point  bent  nearly  at  right  angles 
with  the  stem,  like  the  one  represented 
in  Fig.  110  ;  consequently  the  power  re- 
quired for  introducing  and  consolidating  the  gold  is  applied  to 
great  disadvantage.  But  the  instrument  represented  in  this  cut 
18  only  intended  for  the  first  part  of  the  operation  of  consolidating 
the  metal :  for  its  completion,  smaller  points  are  required. 
20 


298 


FILLING    SUPERIOR    MOLARS    AXD    BICUSPIDS. 


In  filling  a  cavity  in  the  grinding  surface  of  a  first  upper 
molar  on  the  left  side  of  the  mouth,  the  thumb  of  the  left  hand 
may  be  placed  against  the  left  cuspid  or  first  or  second  bicuspid 
as  may  be  most  convenient  to  the  operator ;  while  the  forefinger 
is  placed  behind  tlie  point  of  the  instrument,  and  at  the  same 
time  made  to  push  back  the  commissure  of  the  lips.  To  obtain 
a  good  view  of  the  cavity  in  a  second  or  third  molar  during  the 
operation,  the  cheek  should  be  pressed  from  the  tooth  with  the 
forefinger  of  the  left  hand ;  but  this  finger  can  seldom  be  carried 
far  enough  back  on  this  side  of  the  mouth  to  be  placed  behind 
the  point  of  the  instrument.  During  the  introduction  of  gold, 
the  ring  finger  and  little  finger  of  the  right  hand  should  be  made 
to  rest  on  the  incisor  teeth,  while  the  instrument  is  grasped 
(Fig.  102)  with  the  thumb,  middle,  and  forefinger. 

In  filling  a  cavity  in  the  anterior  approximal  surface  of  a 
right  superior  molar  or  bicuspid,  the  operation  may  be  com- 
menced by  placing  the  gold  against  the  palatine  wall,  and  end- 
ing at  the  buccal.  But  before  the  process  of  condensing  is  com- 
menced, every  portion  of  the  surface  ought  to  be  thoroughly 
tested  with  a  wedge-pointed  instrument,  and  wherever  the  point 
can  be  forced  into  the  gold,  the  cavity  thus  formed  should  be 
filled.  The  instrument  employed  for  the  introduction  of  the 
gold  may  be  like  the  one  represented  in  Fig.  105,  but  having  a 

rather  longer  point;  and  grasped 
as  in  Fig.  102.  For  condensing 
the  extruding  portions,  either  or 
both  of  the  instruments  repre- 
sented in  Figs.  97  and  103  may 
be  used,  as  also  the  one  employed 
for  the  introduction  of  the  gold  ; 
and  one  shaped  as  in  Fig.  Ill 
maybe  sometimes  used  with  great 
advantage.  During  this  part  of 
the  operation,  the  instrument 
may  be  held  as  before,  or  as  seen 
in  Fig.  112,  which  permits  a 
much  greater  amount  of  force  to 
be  applied  than  when  held  in  any 
other  manner. 


Fig.  111. 


Fig.  112. 


FILLING    SUPERIOR    MOLARS   AND    BICUSPIDS.  299 

Nearly  the  same  method  and  the  same  instruments  are  re- 
quired for  filling  a  corresponding  cavity  on  the  opposite  side  of 
the  jaw.  When  practicable,  the  forefinger  of  the  left  hand  should 
be  placed  on  the  palatine  surface  of  the  tooth,  and  the  thumb 
against  the  buccal  surface,  and  in  addition  to  the  instruments 

recommended  for    the    rieht   side    of   the 

.  Fig.  11.^. 

mouth,  the  one  shown  in  Fig.   97  may  be 

very  conveniently  employed  to  introduce 

the  gold ;  also  one  like  Fig.  99,  or  Fig. 

113,    in    condensing   the    surface    of   the 

filling.     The  writer  finds  this  last  particularly  valuable  in  very 

many  cases. 

A  cavity  in  the  posterior  approximal  surface  of  a  superior 
bicuspid  on  either  side  of  the  mouth,  can,  in  the  majority 
of  cases,  be  as  easily  filled  as  one  in  the  anterior  approxiihal 
surface.  The  position  of  the  left  hand  is  very  nearly  the 
same,  and  in  the  introduction  of  the  gold,  the  first  folds 
are  placed  against  the  palatine  wall  of  the  cavity.  By  com- 
mencing on  this  side,  the  operator  is  enabled  to  lay  the  folds 
more  compactly  than  he  could,  were  he  to  commence  at  any 
other  point.  He  also  has  a  more  perfect  control  over  the  in- 
strument in  this  part  of  the  operation,  and  has  a  better  view  of 
the  cavity  during  the  introduction  of  the  gold.  For  consoli- 
dating the  filling,  the  instruments  represented  in  Figs.  98,  99, 
and  104  are  as  well  adapted  to  the  purpose  as  any  that  can  be 
employed. 

When  the  mouth  of  a  patient  is  large,  a  filling  can  often  be 
introduced  with  nearly  as  much  ease  in  the  posterior  approximal 
surface  of  a  first,  or  even  a  second  upper  molar,  as  in  that  of  a 
bicuspid ;  but  when  the  mouth  is  small  and  the  cheeks  fleshy,  it 
often  becomes  a  difficult  and  perplexing  operation.  Although 
the  same  method  is  used ;  yet,  as  it  is  absolutely  necessary  to 
the  introduction  of  a  good  filling,  that  the  operator  should  see 
the  cavity  and  witness  every  part  of  the  operation,  his  ingenuity 
is  often  taxed  to  the  utmost  in  contriving  the  most  suitable 
means  to  enable  him  to  do  it.  A  number  of  instruments  for 
drawing  back  the  corner  of  the  mouth  have  been  invented  ;  but 
the  writer  believes  there  are  none  so  well  suited  to  the  purpose 
as  the  thumb  or  forefinger  of  the  left  hand  of  the  operator.     If 


300  FILLING    SUPERIOR   MOLARS   AXD    BICUSPIDS. 

the  operator  will  accustom  himself  to  the  use  of  a  small  mouth 
glass  held  in  the  left  hand  whilst  operating,  he  will  be  spared 
many  back-breaking  efforts  to  keep  in  view  fillings  on  posterior 
surfaces.  It  is  necessary  to  become  familiar  with  the  apparently 
reverse  motion  of  the  instrument  as  seen  in  the  glass ;  also  to 
accustom  the  three  fingers  of  the  left  hand  to  act  independently 
of  the  thumb  and  forefinger.  But  one  of  the  most  careful  and 
skillful  operators  of  this  or  any  other  country,  Dr.  Maynard, 
assures  us  that  he  works  from  a  reflected  view  in  the  glass  with 
the  same  ease  as  where  he  has  a  direct  view  of  the  cavity,  and 
obtains,  in  very  many  cases  where  he  uses  the  glass,  an  accuracy 
of  view  which  direct  vision  could  not  give  him. 

Before  dismissing  this  part  of  the  subject,  there  is  one  point 
to  which  the  attention  of  the  young  practitioner  should  be  par- 
ticularly directed.  Many,  in  other  respects  tolerably  good 
operators,  are  most  likely  to  fail  in  not  introducing  a  sufficient 
quantity  of  gold  in  the  upper  palatine  portion  of  the  cavity. 
The  author  frequently  meets  with  cases  in  which  the  walls  of 
the  cavity  are  perfectly  sound,  and  every  other  part  of  the  filling 
well  consolidated,  but  here  upon  the  application  of  a  wedge- 
pointed  instrument  the  gold  is  easily  perforated.  He  would, 
therefore,  advise  the  inexperienced  operator  to  test  this  by 
severe  pressure  with  a  sharp  wedge-pointed  instrument,  as  well, 
indeed,  as  every  part  of  the  filling,  before  leaving  the  operation. 
There  is  also  one  other  precaution  applicable  to  fillings  in  the 
approximal  surfaces  of  the  incisors  and  cuspids  as  well  as  of  the 
molars  and  bicuspids ;  it  relates  to  overlapping  portions  of  gold 
under  the  free  edge  of  the  gum,  which  must  be  carefully  and 
completely  removed  before  the  operation  can  be  regarded  as 
complete. 

In  filling  a  cavity  in  the  buccal  surface  of  an  upper  bicuspid 
or  molar,  on  either  side  of  the  mouth,  the  gold  may  be  intro- 
duced with  the  instruments  represented  in  Figs.  95,  105.  The 
latter  is  better  adapted  for  the  left  side,  but  may  also  be  used 
on  the  right.  The  straight  wedge-pointed  instrument  may  also 
be  advantageously  employed  on  this  side.  The  first  folds  of 
gold  should  be  placed  against  the  posterior  wall,  proceeding  from 
behind  forward,  and  pressing  the  folds  against  each  other  as 
compactly  as  possible.     When  the  cavity  has  a  large  orifice,  and 


FILLING    SUPERIOR    MOLARS    AND    BICUSPIDS.  301 

is  rather  shallow,  or  in  other  respects  badly  shaped  for  the 
retention  of  the  gold,  the  operation  is  often  tedious,  difficult, 
and  perplexing.  But  under  favorable  circumstances  a  filling 
maj  be  almost  as  readily  introduced  here  as  in  any  other  part. 

The  palatine  surface  of  a  bicuspid  or  of  a  molar  is  rarely 
attacked  by  caries  ;  on  the  latter  it  is  usually  seated  in  a  de- 
pression at  the  termination  of  a  fissure  leading  from  the  posterior 
depression  in  the  grinding  surface.  It  is  usually  situated  near 
the  posterior  palato-approximal  angle  of  the  crown  about  half 
way  between  the  gum  and  the  coronal  extremity  of  the  tooth. 
It  sometimes  happens  that  the  walls  of  these  fissures  are  affected 
with  caries  throughout  their  whole  extent,  requiring  to  be  filled 
from  the  depression  in  the  grinding  to  its  termination  on  the 
palatine  surface.  In  this  case,  the  portion  of  the  cavity  on  the 
grinding  surface  may  be  first  filled  ;  then  the  operator  may  pro- 
ceed to  fill  the  palatine  portion  in  the  same  manner  as  if  it  were 
a  simple  cavity,  placing  the  first  folds  of  foil,  in  the  case  of  a 
right  molar,  against  the  upper  and  posterior  side  of  the  opening 
with  an  instrument  like  the  one  represented  in  Fig.  105.  Great 
care  is  necessary  to  prevent  the  instrument  from  slipping.  It 
often  happens,  too,  that  the  orifice  becomes  choked  with  foil 
before  the  cavity  is  half  filled.  This,  indeed,  is  liable  to  occur 
in  filling  any  cavity  in  any  tooth ;  and  when  it  does  happen, 
unless  a  sufficient  amount  of  pressure  is  applied  to  make  a  free 
opening  into  it,  the  filling  Avill  be  imperfect  and  the  object  of 
the  operation  wholly  defeated.  When  the  cavity  is  situated  in 
a  left  molar,  the  gold  may  be  introduced  with  the  instruments 
represented  in  Figs.  95,  108,  placing  the  first  folds  against  the 
upper  wall  of  the  cavity,  and  proceeding  downward. 

The  curvatures  of  the  points  of  condensing  instruments  may  be 
similar  to  those  employed  for  the  introduction  of  the  gold.  The 
process  of  condensing  the  extruding  portion  of  a  filling  in  the 
buccal  or  palatine  surface  of  a  molar,  as  well  as  in  the  approxi- 
mal  surface  of  almost  any  isolated  tooth,  may  be  greatly  aided 
by  properly  constructed  forceps.  The  following  cut  will  convey 
a  more  correct  idea  of  their  construction  than  any  description 
that  can  be  given.  They  are  provided  with  both  straight  and 
curved  points,  see  Fig.  114,  a,  6,  t\  and  are  used  by  placing  the 
flat  jaw,  covered  Avith  raw  cotton  or  a  cushion,  against  the  sound 


302 


FILLING    THE    INFERIOR    INCISORS    AND    CUSPIDS 


side  of  the  tooth,  and  the  condensing  point  against  the  filling  ; 
force  is  applied  by  pressing  the  handles  together.     In  this  way 

Fio.   114. 


as  much  pressure  may  be  exerted  upon  the  filling  as  the  tooth 
■will  bear.  It  is  only,  however,  in  the  fewest  number  of  cases 
that  this  instrument  can  be  advantageously  employed.  The 
credit  of  the  invention  belongs,  we  believe,  to  the  late  Dr.  H.  H. 
Hay  den. 

A  tubercle,  of  greater  or  less  size,  is  sometimes  found  on  the 
anterior  palatine  surface  of  a  molar,  near  the  crown.  Between 
this  and  the  body  of  the  crown,  a  deep  depression  is  often  seen, 
which  becomes  the  seat  of  caries  ;  but  the  removal  of  the  diseased 
part,  and  the  introduction  of  a  filling  is  so  simple,  that  a  special 
description  of  the  operation  is  not  deemed  necessary. 


FILLIXG  THE  INFERIOR  INCISORS  AND  CUSPIDS. 

The  operation  of  filling  a  lower  incisor  or  cuspid  is  far  more 
difficult  than  filling  an  upper.  It  is  fortunate,  therefore,  both 
for  the  dentist  and  the  patient,  that  the  lower  incisors  and  cuspids 
are  less  liable  to  caries  than  the  upper. 

The  constant  tendency  of  the  lower  jaw  to  change  its  posi- 
tion, is  embarrassing  to  the  dentist  in  operating  on  any  of  the 
teeth  in  it,  and  in  case  of  the  incisors  and  cuspids  it  is  some- 
times peculiarly  perplexing.  To  prevent  this,  all  the  effort  the 
operator  can  make  with  his  left  hand,  is  frequently  required. 
From  the  backward  inclination,  too,  of  these  teeth,  it  rarely 
happens  that  the  gold  can  be  introduced  from  the  lingual  side  of 
the  arch  ;  consequently,  it  is  necessary  to  make  the  space  as 
wide  anteriorly  as  posteriorly.  But  as  the  teeth  are  compara- 
tively small,  the  separation,  when  made  with  a  file,  should  be  no 
wider  than  is  absolutely  necessary  for  the  removal  of  the  diseased 


FILLING    THE    INFERIOR    INCISORS    AND    CUSPIDS.  303 

part  and  the  introduction  of  the  gold.  When,  however,  it  can 
be  done  with  safety,  the  separation  shouhl  be  made  with  a  piece 
of  gum  ehistic  or  other  substance  between  the  teeth,  in  the 
manner  before  described. 

While  operating  on  the  lower  teeth,  the  head  of  the  patient 
should  occupy  a  more  perpendicular  position  than  while  opera- 
ting on  the  upper ;  this  may  be  done  either  by  lowering  the  seat 
or  raising  the  head-piece  of  the  chair.  When  by  the  latter,  it 
will  be  occasionally  necessary  for  the  operator  to  stand  upon  a 
stool  five  or  six  inches  in  height. 

In  filling  a  cavity  in  the  right  approximal  surface  of  a  lower 
incisor  or  cuspid,  the  following  method  is  recommended.  The 
cavity  being  prepared,  and  a  sufiicient  quantity  of  gold  foil  made 
into  a  small  roll,  or  folded  lengthwise,  as  the  operator  may  pre- 
fer ;  with  the  left  arm  over  the  patient's  head,  the  chin  is  gently 
grasped  with  the  left  hand,  while  the  thumb  is  placed  against  the 
lingual  surface  of  the  tooth — the  forefinger  serving  to  direct  the 
gold  and  point  of  the  instrument,  and  also  to  depress  the  lower 
lip.  The  folds  of  gold  in  their  introduction  are  pressed  firmly 
against  the  lower  wall  of  the  cavity.  The  instrument  employed 
for  this  purpose  may  be  shaped  like  the  one  represented  in  Fig. 
Fig.   115.  Fig.  IIG. 


115,  with  a  very  small  wedge-shaped  point,  and  held  as  in  Fig. 
102.  The  consolidation  of  the  gold  may  be  effected  partly  with 
the  same  instrument,  partly  with  a  round-pointed  one,  shaped  as 
shown  in  Fig.  116,  and  partly  with  an  instrument  shaped  as  in 
Fig.  104.  The  tooth  should  be  firmly  held  between  the  thumb 
and  fore-finger  of  the  left  hand,  to  prevent  it  from  being  moved 
in  its  socket  by  the  pressure  of  the  instrument. 

When  the  incisors  are  very  small,  and  the  caries  has  spread 
over  a  large  portion  of  the  side  of  the  tooth,  it  is  often  difficult 
to  form  a  suitable  cavity  for  the  retention  of  a  filling,  without 
penetrating  to  the  pulp  cavity.  In  such  cases,  the  patience  and 
skill  of  the  operator  are  frequently  taxed  severely  in  obtaining 
a  sufficiently  secure  support  for  the  gold.  But  this  he  can  usually 
do,  if  he  can  make  the  bottom  of  the  cavity  as  large  as  the 
orifice,  even  though  it  have  but  little  depth. 


304  FILLING    THE    INFERIOR    MOLARS    AND    BICUSPIDS. 

The  manner  of  introducing  a  filling  in  the  left  approximal 
surface  is  very  similar.  The  left  arm  and  hand,  as  well  as  the 
thumb  and  fore-finger,  are  all  disposed  of  in  the  manner  just  de- 
scribed. The  same  instruments,  too,  maybe  employed  for  intro- 
ducing and  consolidating  the  gold,  though,  in  the  first  part  of 
the  operation,  the  instrument  (Fig.  100)  may  often  be  advantage- 
ously substituted  for  the  one  in  Fig.  115. 

Nothing  has  been  said  with  regard  to  fillings  in  the  labial  or 
lingual  surface  of  lower  incisors  and  cuspids.  Although  caries 
rarely  attacks  either  of  these  surfaces  of  a  lower  incisor,  it  does 
sometimes  develop  itself  in  the  labial  surface  of  a  cuspid ;  but 
the  operation  of  introducing  a  filling  here  is  so  simple,  that  a 
separate  description  of  the  manner  of  it  is  not  deemed  necessary. 

FILLING  THE  INFERIOR  iMOLARS  AND  BICUSPIDS. 

In  filling  a  cavity  in  the  grinding  surface  of  a  right  lower 
molar  or  bicuspid,  the  operator  may  stand  on  the  same  side  of 
his  patient,  and  a  few  inches  higher  than  while  operating  on  an 
incisor  or  cuspid.  With  his  left  arm  placed  over  his  patient's 
head,  the  tooth  may  be  grasped  with  the  thumb  and  forefinger 
of  the  left  hand,  while  the  middle  finger  is  placed  by  the  side  of 
the  chin;  the  other  two  should  be  placed  beneath  it.  After  pre- 
paring the  cavity,  the  gold  may  be  introduced  with  an  instrument 
like  the  one  represented  in  Fig.  108,  and  held  as  shown  in  Fig. 
102,  pressing  the  folds  against  the  posterior  wall  of  the  cavity. 

In  condensing  the  gold  after  the  cavity  is  filled,  use  the  in- 
strument represented  in  Fig.  109.  Sometimes,  however,  the  one 
shown  in  Fig.  Ill,  which  may  be  held  as  seen  in  Fig.  96,  an- 
swers a  better  purpose ;  but  a  greater  amount  of  force  can  be 
exerted  when  held  in  the  manner  shown  in  Fig.  112,  previously 
wrapping  it  with  the  corner  of  a  napkin,  to  prevent  the  small 
part  of  the  instrument  from  hurting  the  little  finger.  The  kind 
of  instrument,  and  the  manner  of  holding  it,  will,  after  all,  have 
to  be  determined  by  the  operator.  During  the  introduction  and 
consolidation  of  the  gold,  the  lower  jaw  should  be  firmly  held 
with  the  left  hand,  to  prevent  it  from  moving  and  from  being  too 
much  depressed.  This  precaution  is  the  more  necessary,  as  the 
muscles  of  the  lower  jaw  and  the  articular  ligaments  are  seldom 


FILLING    THE    INFERIOR    MOLARS    AND    BICUSPIDS.  305 

Strong  enough  to  resist  the   amount  of  force  required  in  the 
operation. 

In  filling  a  cavity  in  the  grinding  surface  of  a  tooth  on  the 
left  side,  the  dentist  may  sometimes  operate  to  greater  advantage 
by  standing  on  the  same  side.  In  this  case,  the  commissure  of 
the  lips  should  be  pressed  back  with  the  thumb  of  the  loft  hand, 
placing  it  on  or  against  the  tooth  to  be  filled,  while  the  fore- 
finger passes  in  front  of  the  chin,  and  the  other  three  beneath 
it.  As  a  general  rule,  however,  he  will  be  able  to  operate  more 
conveniently  by  standing  on  the  right  side  of  his  patient,  and 
holding  the  tooth  and  chin  in  the  manner  before  directed.  In 
either  case,  the  gold,  in  its  introduction,  should  be  pressed 
against  the  posterior  wall  of  the  cavity. 

The  foregoing  general  directions  will  be  found,  for  the  most 
part,  applicable  to  the  introduction  of  a  filling  in  the  approximal 
surfaces.  When  the  crowns  of  the  teeth  are  long,  and  the  cavity 
situated  near  the  gum,  the  operation  is  sometimes  very  difficult 
and  tedious,  requiring  all  the  patience  and  skill  the  dentist  can 
exercise  to  accomplish  it  securely.  This  difficulty  is  increased 
when  the  shape  of  the  cavity  is  unfavorable  for  the  retention  of 
the  gold  ;  or,  in  other  words,  when  the  cavity  is  shallow  and  has 
a  large  orifice.  There  is  also  another  very  serious  difficulty 
which  the  operator  encounters  in  the  introduction  of  a  filling  in 
the  approximal,  and  also  in  the  buccal,  surface  of  a  lower  molar 
or  bicuspid.  The  flow  of  saliva  is  often  so  profuse,  that  the 
whole  of  the  lower  part  of  the  mouth  is  completely  filled,  and 
the  tooth  inundated  before  it  is  possible  to  introduce  a  sufficient 
quantity  of  gold  to  fill  the  cavity.  This  not  only  retards  the 
operation,  but  it  also  renders  it  more  difficult  and  perplexing; 
for  it  is  necessary  to  force  out  every  particle  of  moisture  from 
the  cavity  and  from  between  the  different  layers  of  gold,  before 
the  necessary  cohesive  attraction  between  them  can  be  secured. 
If  this  is  not  done,  or  at  any  rate,  if  all  the  moisture  is  not 
forced  from  the  cavity,  and  the  gold  sufficiently  consolidated  to 
render  it  impermeable  to  the  fluids  of  the  mouth,  the  operation 
will  be  unsuccessful. 

Ordinary  foil,  sometimes  called  non-adhesive,  when  introduced 
in  folds  lying  parallel  with  the  sides  of  the  cavity,  keeps  its 
place  by  the  close  lateral  contact  of  the  folds  against  each  other 


306  FILLING    THE    INFERIOR    MOLARS    AND    BICUSPIDS. 

and  the  walls  of  the  cavity.  Hence  such  fillings  may  prove  suc- 
cessful, although  done  ''under  water,"  provided  the  lateral  press- 
ure is  suflBcient  to  force  out  the  saliva  from  between  the  layers 
of  foil.  But  if  the  folds  are  laid  in  parallel  with  the  bottom  of 
the  cavity,  the  operation  will  fail,  in  consequence  of  the  scaling 
off  of  the  successive  layers  which  have  no  adhesion.  Crystal 
gold  and  adhesive  foil  fillings  depend  for  their  success  upon  the 
perfect  adhesion  of  their  component  pieces;  therefore,  the 
slightest  moisture,  or  even  dampness,  whilst  being  introduced,  is 
fatal  to  their  durability. 

For  the  purpose  of  obviating  this  difficulty,  a  variety  of  means 
have  been  proposed,  but  the  one  principally  relied  on  consists  in 
placing  the  corner  of  a  soft  fine  linen  napkin,  or  what  is  still 
better,  fine  tissue  or  bibulous  paper,  ou  each  side  of  the  tooth,  so 
as  to  form  a  sort  of  dam  or  wall  around  it.  This  may  sometimes 
be  successfully  done,  but  in  many  cases  it  will  fail  to  accomplish 
the  object,  by  increasing  the  flow  of  saliva,  and  is  more  or  less 
embarrassing  to  the  operator. 

In  the  introduction  of  the  gold  on  the  right  side,  it  may  be 
pressed  against  the  buccal  wall  of  the  cavity  on  the  left  side, 
against  the  lingual  wall.  Either  of  the  instruments  represented 
in  Figs.  94  and  105  may  be  employed  for  the  introduction  of  the 
gold,  whether  the  cavity  be  situated  in  the  anterior  or  posterior 
approximal  surface  of  the  tooth,  and  may  be  held  in  the  hand  in 
the  manner  shown  in  Fig.  102. 

In  filling  a  cavity  in  the  lingual  and  posterior  approximal 
angle  of  a  first  or  second  left  bicuspid,  and  especially  from  the 
loss  of  the  tooth  behind  it,  when  there  is  a  backward  inclination 
of  the  organ,  great  cure  is  necessary  to  prevent  the  instrument 
from  slipping  and  wounding  the  lower  lip.  The  most  convenient 
position  for  the  operator  in  this  case  is  on  the  left  side  and  partly 
in  front  of  the  patient.  The  tooth  may  then  be  firmly  grasped 
between  the  thumb  and  fore-finger  of  the  left  hand,  or  the  thumb 
alone  pressed  against  the  outside  of  the  tooth  ;  in  either  case  it 
is  to  be  used  as  a  rest  for  the  ring-finger  of  the  right  hand,  dur- 
ing the  introduction  and  consolidation  of  the  gold.  But  the 
locality  of  the  cavity  is  such,  especially  when  the  mouth  of  the 
patient  is  small,  that  it  can  only  be  seen  with  great  difficulty. 
Hence  tiie  operator  is  constantly  liable  to  place  the  point  of  the 


FILLING    THE    INFERIOR    MOLARS    AND    BICUSPIDS.  307 

instrument  on  one  side  of  the  orifice  against  an  overlapping  por- 
tion of  gold,  which,  when  pressure  is  applied,  is  cut  through  or 
detached.  The  instrument  thus  comes  in  contact  with  the  hard, 
smooth  enamel,  and  unless  the  hand  is  so  guarded  as  to  control 
its  motions,  it  is  liable  to  slip  and  wound  some  part  of  the  mouth, 
especially  the  lower  lip :  which  accident,  unless  proper  precau- 
tion is  observed,  may  occur  in  filling  any  tooth. 

Among  the  principal  difficulties  which  the  dentist  encounters 
in  filling  a  cavity  in  the  buccal  surface  of  a  lower  molar,  apart 
from  that  of  keeping  the  cavity  dry  until  the  gold  is  introduced, 
is  the  contact  of  the  lower  and  inner  part  of  the  cheek  with  the 
tooth.  This  may,  to  a  considerable  extent,  be  prevented,  and 
the  commissure  of  the  lips  at  the  same  time  pushed  back,  with 
the  forefinger  of  the  left  hand  of  the  operator ;  which  also  will 
serve,  when  the  cavity  is  shallow  and  the  orifice  large,  to  hold 
the  gold  in  place,  until  a  sufficient  quantity  is  introduced  to  ob- 
tain support  from  the  surrounding  walls :  it  is  sometimes,  how- 
ever, attended  with  much  difficulty.  In  operating  upon  the 
bicuspids,  it  is  only  necessary  to  depress  the  corner  of  the  mouth 
to  obtain  free  access  to  the  cavity. 

An  instrument  has  been  invented  by  C.  C.  Thomas,  of  Loui- 
siana, for  the  purpose  of  keeping  the  cheek  from  the  buccal  sur- 
face of  the  lower  molars,  depressing  the  tongue  and  holding  the 
jaws  at  a  sufficient  distance  apart. 

Fig.   117. 


It  consists  of  (Fig.  117,)  two  grooved  plates  to  admit  the  molar 
teeth,  which  may  be  separated  or  brought  together  by  a  screw 
working  in  a  cylinder.  Around  the  cylinder  are  two  collars 
which  can  be  tightened  by  set-screws  :  to  the  lower  is  soldered  a 


308  FILLING    THE    INFERIOR    MOLARS    AND    BICUSPIDS. 

rod  on  which  moves  a  ring  holding  a  hand-shaped  tongue-hohler  : 
to  the  upper  is  attached  a  highly  polished  oval  concave  plate, 
connected  with  the  shaft  by  a  ball  and  socket  joint ;  the  shaft 
itself  is  capable  of  extension  by  a  ratchet  movement.  The  in- 
strument is  ingeniously  contrived  so  that  its  several  parts  can 
be  moved  in  any  required  direction  and  extent.  Its  application 
is  obvious :  it  opens  the  mouth,  keeps  the  tongue  and  cheek  out 
of  the  way,  and  the  oval  mirror  throws  light  on  the  cavity.  The 
author  has  not  tested  its  practical  value,  but  thinks  it  might  be 
advantageously  used,  especially  in  operating  on  the  left  lower 
molars. 

For  the  introduction  of  the  gold  on  the  right  side,  either  of 
the  instruments,  represented  in  Figs.  95  and  105,  may  be  em- 
ployed, but  on  the  left  side  the  latter  will  generally  be  found 
most  convenient.  A  straight  wedge-pointed  instrument,  (Fig. 
118,)  can  often  be  advantageously  used  in  introducing  the  foil 
in  either  of  the  right  bicuspids,  and  some- 
times even  in  the  first  molar.  This  instru- 
ment can  also  often  be  used  in  filling  a 
cavity  in  the  grinding  surface  of  a  molar  of 
either  jaw,  but  oftener  in  the  upper  than  the  lower.  It  is 
scarcely  necessary  to  say,  that  the  introduction  of  the  gold 
should  commence  behind  and  proceed  forward.  The  instruments 
represented  in  Figs.  98,  lOG  and  107,  may  be  used  in  consolidat- 
ing the  foil. 

It  may  be  well  to  mention  here,  that  in  filling  a  molar  or  bi- 
cuspid on  the  left  side  in  the  lower  jaw,  whether  in  the  grinding, 
approximal  or  buccal  surface,  the  back  of  the  chair,  if  so  con- 
structed as  to  admit  of  being  moved,  should  be  thrown  five  or  six 
inches  farther  back,  to  lower  the  head  of  the  patient  and  give 
the  face  a  more  horizontal  inclination.  By  this  means  the  opera- 
tor is  enabled  to  approach  the  locality  of  his  manipulations  with 
greater  ease,  thus  enabling  him  to  exercise  a  more  perfect  con- 
trol over  his  instrument,  as  well  as  over  the  mouth.  But  if  the 
back  of  his  operating  chair  is  stationary,  he  should  stand  upon 
a  stool  of  five  or  six  inches  in  height. 

A\  hen  the  cavity  is  situated  near  the  gum,  or  when  the  lower 
part  of  it  runs  a  little  under  its  margin,  the  precaution  of  remov- 
ing all  the  overlapping  portions  ought  never  to  be  omitted,  and 


FILLING   THE    INFERIOR    MOLARS    AND    BICUSPIDS.  309 

this  sometimes  constitutes  a  difficult  part  of  the  operation.     For 
this  purpose,  the  file  represented  in  Fig.  119,  may  be  very  ad- 

FiG    119. 


vantageously  used.  Some  are  made  straight  at  each  end,  others 
are  curved.  These  valuable  instruments  were  invented  by  Dr. 
Elisha  Townsend  ;  they  are  very  useful,  not  only  for  the  purpose 
just  stated,  but  also  for  filing  down  the  surplus  gold  of  a  filling 
in  the  approximal  and  other  surfaces  of  all  the  teeth. 

The  profession  is  now  well  supplied  Avith  these  files,  having  an 
almost  endless  variety  of  shape,  size,  and  fineness  of  cut.  It  is 
difficult  to  over  estimate  the  utility  of  these  indispensable  instru- 
ments. Different  makers  seem  to  vie  with  each  other  in  devis- 
ing new  forms.  A  valuable  modification  has  lately  been  sug- 
gested by  Dr.  Edward  Maynard.  It  is  to  make  the  two  ends 
different — not  in  shape,  as  is  usually  done — but  in  the  direction 
of  the  file  cut :  or  rather  to  have  the  file  on  each  end  set  in  the 
saine  direction,  marked  by  an  arrow  on  the  shaft.  Thus  one  end 
will  cut  totvard  the  other  from  the  operator ;  which,  as  the  two 
movements  are  constantly  required  upon  the  same  filling,  adds 
greatly  to  the  value  of  the  instrument.  Whereas  a  difference  in 
the  shape  of  the  two  ends  is  rather  an  annoyance,  and  precise 
similarity  of  no  use  except  on  the  score  of  economy. 

The  foregoing  details,  with  regard  to  the  manner  of  filling 
teeth,  will  serve  as  a  general  guide  for  the  performance  of  the 
operation ;  and  at  the  same  time,  give  to  the  student  and  inex- 
perienced practitioner,  some  idea  of  the  amount  of  labor,  accu- 
racy of  manipulation,  and  perfection  of  execution,  it  requires. 

The  manner  of  building  up  the  whole  or  part  of  the  crown  of 
a  tooth,  will  be  described  in  a  subseqent  chapter. 


CHAPTERFIFTH.  ? 


FILLING    TEETH    WHEN    THE    LINING    MEMBRANE   IS 

EXPOSED. 

The  propriety  of  filling  a  tooth  after  the  invasion  of  the  pulp 
cavity  by  caries,  without  first  destroying  the  pulp,  is  doubted 
by  many  practitioners.  It  is  thought  that  inflammation  and 
suppuration  of  the  lining  membrane  and  pulp  must  necessarily 
result  from  the  operation.  But  Dr.  Koecker,  who  was  the  first 
to  recommend  filling  a  tooth  under  such  circumstances,  cites  a 
number  of  cases  in  which  he  performed  the  operation  successfully. 
He  also  expresses  the  belief  that  "  on  an  average,  five  out  of  six 
teeth  may  be  preserved  alive,  and  rendered  useful  for  a  long 
while."  The  author  has  been,  since  1846,  in  the  constant  habit  of 
filling  teeth  under  such  circumstances,  whenever  a  favorable  case 
presented  itself,  and  occasionally  for  nearly  twelve  years  pre- 
viously to  this  period ;  and  his  experience  warrants  the  belief, 
that  the  vitality  of  even  a  larger  proportion  may  be  saved  under 
skillful  treatment.  lie  believes  he  has  been  successful  in  at 
least  fourteen  cases  out  of  every  fifteen,  since  1853 ;  and  it  may 
be,  as  he  has  stated  in  another  place,  that  when  the  treatment 
of  teeth  in  which  caries  has  penetrated  to  the  pulp-cavity  shall  be 
better  understood,  the  vitality  of  a  still  larger  relative  proportion 
may  be  preserved.  But  so  long  as  it  can  be  done  in  even  nine 
cases  out  of  ten,  the  operation  must  be  regarded  as  valuable ; 
for  a  healthy  living  tooth  is  less  liable  to  become  obnoxious  to 
the  surrounding  parts  than  one  deprived  of  a  large  portion  of  its 
vitality. 

Admitting  the  fact  that  teeth  can,  in  many  cases,  be  pre- 
served alive  after  the  lining  membrane  has  become  exposed,  the 
question  arises,  does  the  pulp  remain  in  the  condition  in  which 
it  is  at  the  time  the  operation  is  performed  ?  It  is  difficult  to 
conceive  either  how  a  vacant  space  can  exist  between  it  and  the 
filling,  or  how  a  foreign  body  can  remain  in  contact  with  it,  Avith 


FILLING    TEETH    OVER    EXPOSED    LINING    MEMBRANE.       311 

impunity.  Drs.  Harwood,  of  Boston,  and  J.  H.  Foster  and  W. 
H.  Dwinelle,  of  New  York,  hold  the  opinion,  from  experiments 
they  have  made,  that  it  ossifies.  That  some  change  of  this  sort 
does  take  pLace,  is  well  known,  and  the  transition  is  evidently 
the  result  of  increased  vascular  action,  caused  by  irritation. 
Examples  of  such  ossification  are  met  Avith  in  teeth  in  which  the 
crowns  have  lost  a  considerable  portion  of  their  substance  from 
mechanical  or  spontaneous  abrasion  ;  and  it  is  a  beautiful  pro- 
vision of  nature  to  prevent  the  exposure  of  these  delicate  and 
highly  sensitive  parts.  The  same  thing  sometimes  occurs  in 
teeth  which  have  suffered  no  loss  of  substance,  and  is  doubtless 
the  result  of  some  constitutional  or  local  cause  of  irritation. 

These  facts  would  seem  to  justify  the  conclusion  elsewhere 
stated,  that  the  pulp  of  a  tooth,  when  subjected,  for  a  sufficient 
length  of  time,  to  the  influence  of  an  irritating  agent,  capable  of 
exciting  only  a  very  slight  inflammatory  action,  undergoes  ossi- 
fication ;  or  rather  is  converted  into  a  substance  resembling  crusta 
petrosa,  or  what  Professor  Owen  terms  osteo-dcntine.  A  tooth 
which  has  been  filled  after  the  lining  membrane  has  become  ex- 
posed, is  liable,  when  it  fails  to  undergo  this  change,  either  to 
perish  from  derangement  of  its  nutritive  functions,  or  to  become 
the  seat  of  active  inflammation  and  suppuration.  But  something 
more  than  ossification,  or  conversion  into  osfeo-dentine,  takes 
place  when  a  space  is  left  between  it  and  the  filling.  If  this 
vacant  space  were  not  filled  up,  we  have  reason  to  believe  that 
the  slightest  increase  of  vascular  action  would,  as  has  been  justly 
remarked  by  Dr.  Elliot,  force  a  portion  of  the  pulp  into  it;  and 
thus  active  inflammation  would  be  excited  by  contact  with  the 
sharp  angles  of  the  walls  of  the  cavity,  and  this,  as  a  natural 
consequence,  would  be  apt  to  terminate  in  suppuration.  We 
believe,  from  experiments  which  we  have  made,  that  nature,  ever 
fruitful  in  her  resources,  uses  means  for  the  prevention  of  such 
an  occurrence  :  consisting,  first,  in  filling  the  vacant  space  with 
coagulable  lymph,  effused  from  the  lining  membrane  or  exposed 
surface  of  the  pulp  ;  then,  in  its  organization,  and,  lastly,  its 
conversion  into  bone,  or  more  properly,  osteo-deiidne.  Nature 
seems  to  employ  here  the  same  means  as  in  other  parts  of  the 
body,  for  the  reparation  of  injuries. 

When  this  reparative  process  does  not  take  place  after  the 


312       FILLING    TEETH    OVER    EXPOSED    LINING    MEMBRANE. 

operation,  it  may  be  owing  either  to  want  or  the  excess  of  vas- 
cular action  in  the  lining  membrane  or  pulp.  A  certain  amount 
of  increased  vascular  action  seems  necessary  to  the  effusion  of 
coagulable  lymph,  an  indispensable  requisite  ;  but  when  this  is 
too  great,  it  must  of  necessity  terminate  in  suppuration.  It  is 
obvious,  therefore,  that  the  success  of  the  operation  must  very 
greatly  depend  upon  the  circumstances  under  which  it  is  per- 
formed. If  these  be  unfavorable,  all  eflforts  to  preserve  the 
vitality  of  the  organ  will,  in  a  majority  of  cases,  prove  unavail- 
ing ;  however  skillful  the  operator  may  be  in  the  preparation  of 
the  cavity  and  the  introduction  of  the  gold.  The  health  of  the 
patient  should  be  unimpaired ;  the  tooth  of  a  tolerably  good 
quality,  free  from  pain  at  the  time  the  operation  is  performed ; 
it  should  never  have  ached ;  and  the  pulp,  peridental  membrane 
and  surrounding  parts  should  be  in  a  perfectly  healthy  condition. 
The  cavity  should  be  of  a  proper  shape  for  the  easy  introduction 
and  permanent  retention  of  the  filling  ;  and  the  smaller  the  point  of 
exposure  of  the  lining  membrane,  the  greater  the  prospect  of  suc- 
cess. It  is  also  important  that  every  particle  of  completely 
decomposed  dentine  be  removed,  and  if  there  be  any  oozing  of 
blood  from  the  ruptured  vessels,  this  must  cease  before  the  fill- 
ing is  introduced. 

Dr.  Koecker's  method  of  performing  the  operation  is  as 
follows : 

First. — Remove  the  caries  and  give  to  the  cavity  a  proper 
shape  for  the  reception  and  retention  of  the  filling ;  then  with  a 
little  raw  cotton  moistened  in  warm  water,  free  it  of  all  dust  that 
may  be  in  contact  with  the  pulp.  Second. — If  the  lining  mem- 
brane is  not  wounded,  dry  the  cavity,  and  place  a  small  plate  of 
thin  leaf  lead  over  the  exposed  nerve  and  surrounding  dentine ; 
then  fill  the  cavity  in  the  ordinary  way  with  gold.  Third. — 
When  the  lining  membrane  is  wounded  and  bleeds,  cauterize  the 
part  with  an  iron  wire,  heated  to  a  red  heat,  using  the  pre- 
caution not  to  wound  the  pulp.  After  the  hemorrhage  has  been 
arrested  and  an  artificial  cicatrix  formed,  free  the  cavity  from 
all  loose  extraneous  matter,  then  cover  the  nerve  with  sheet  lead 
and  fill  as  before  directed.  The  reason  assigned  by  Dr.  Koecker 
for  covering  the  nerve  Avith  lead,  is  that  it  has  a  "  more  cooling 
and  anti-inflammatory  effect"  than  gold.     He  also  states  that 


FILLING    TEETH    OYER    EXPOSED    LINING    MEMBRANE.       313 

when  he  employed  gold  exclusively,  he  was  seldom  successful, 
and  that  inflammation,  pain,  etc.,  generally  supervened,  render- 
ing the  removal  of  the  filling  necessary. 

The  foregoing  method  of  treating  an  exposed  dental  pulp  has 
not  proved  so  successful  in  the  hands  of  other  practitioners.  It 
has  been  found  that  inflammation  and  suppuration  supervene  in 
a  large  majority  of  the  cases,  especially  when  the  cautery  is 
used ;  the  practice  is  now  seldom  resorted  to.  The  direct  appli- 
cation of  any  metallic  substance  to  the  lining  membrane  or  pulp, 
is,  according  to  the  observation  of  the  author,  very  apt  to  be 
followed  by  inflammation  and  suppuration  of  these  tissues.  Some 
of  the  vessels  of  the  lining  membrane  are  always  necessarily 
wounded  in  removing  the  last  layer  of  decomposed  dentine,  but 
the  hemorrhage,  when  no  other  injury  is  inflicted,  is  very  slight, 
and  sometimes  scarcely  perceptible ;  so  that  the  operation  of 
filling  need  never  be  delayed  more  than  from  three  to  ten 
minutes.  The  application  of  a  small  particle  of  raw  cotton 
moistened  with  spirits  of  camphor  will  immediately  arrest  it. 

Dr.  S.  S.  Fitch  proposes  to  cover  the  nerve  when  exposed, 
with  a  plate  of  gold,  previously  to  filling  the  cavity ;  and  this, 
in  the  opinion  of  the  author,  is  preferable  to  the  direct  applica- 
tion of  a  piece  of  leaf  lead,  as  recommended  by  Dr.  Koecker. 
It  is  certainly  a  better  protection  to  the  nerve,  and  if  it  be  fitted 
to  the  cavity  so  that  its  edges  shall  rest  upon  the  surrounding 
dentine,  a  filling  may  afterwards  be  introduced  without  injury  to 
the  pulp.  Still,  in  many  cases  the  application  of  a  covering  of 
this  sort  is  objectionable.  It  is  difficult  to  fit  it  with  sufficient 
accuracy  to  prevent  the  liability  to  displacement  in  the  introduc- 
tion of  the  filling ;  and  when  the  cavity  is  very  shallow  it  will 
occupy  so  much  room  as  to  render  it  impossible  to  fill  the  re- 
mainder of  it  in  a  substantial  manner ;  yet  it  may  sometimes  be 
very  advantageously  applied. 

The  plan  pursued  by  Dr.  J.  H.  Foster,  in  filling  teeth  after 
the  pulp  has  become  exposed  or  is  covered  only  by  a  very  thin 
layer  of  dentine,  is  as  follows :  "  If,"  says  he,  "  after  a  careful 
removal  of  all  the  defective  portion,  within  and  about  the  parie- 
tes  of  the  cavity,  the  thin  layer  of  bone  which  lies  adjacent  to 
the  lining  membrane  has  a  moderate  degree  of  consistency,  yet 
not  suflScient  to  protect  the  dental  pulp  from  irritation  caused 
21 


314       FILLING   TEETH    OVER    EXPOSED    LINING   MEMBRANE. 

by  the  pressure  of  external  agents;  it  has  been  my  practice  to 
leave  it  there,  and  after  fitting  a  gold  cap  over  it  (with  great 
caution  as  to  its  proper  adjustment  as  a  protection),  proceed  to 
fill  the  tooth."  But  this  method,  he  says,  was  not  as  successful 
as  he  could  have  desired,  owing,  as  he  supposed,  to  the  extent 
to  which  the  thin  subjacent  layer  of  dentine  had  been  involved 
in  disease,  and  to  the  liability  of  the  pulp  to  be  affected  by  heat 
and  cold. 

To  guard  against  the  irritation  and  inflammation  proceeding 
from  this  cause,  he  fills  the  concave  surface  of  the  gold  cap  with 
Hill's  stopping ;  using  the  precaution  to  preserve  the  concavity, 
so  that  it  may  not  press  upon  the  part  it  is  designed  to  protect. 
This  treatment,  he  says,  proved  successful  in  a  majority  of  cases. 
Believing  that  many  failures  occurred  in  consequence  of  the 
comparatively  small  portion  of  newly  exposed  bone  which  was 
covered  and  protected  by  the  non-conducting  medium,  he  resolved 
to  try  still  another  experiment.  Instead  of  lining  the  gold  cap, 
after  having  fitted  it  accurately  upon  the  floor  of  the  cavity,  he 
filled  the  whole  of  the  cavity  external  to  it,  with  Dr.  Hill's  com- 
position, allowing  this  to  remain  for  five  or  six  months  as  a  tem- 
porary stopping. 

By  this  plan,  Dr.  Foster  says  he  has,  with  one  or  two  excep- 
tions, been  successful  in  preserving  the  vitality  of  the  tooth  in 
every  case  treated  during  the  past  year  (1850).  He  also  states 
that  he  has  occasionally  removed  these  fillings  after  the  lapse  of 
two  or  three  months,  and  finding  the  irritability  of  the  tooth  still 
existing,  he  refilled  them  in  the  same  manner  and  permitted 
the  filling  to  remain  two  or  three  months  longer ;  on  again  re- 
moving the  stoppings,  he  found  the  inflammation  diminished,  and 
the  subjacent  layer  of  bone  almost  firm  enough  to  bear  the  pres- 
sure of  a  gold  filling ;  but  he  still  uses  the  cap  underneath  the 
gold,  as  before.  He  believes  however  that,  if  Hill's  stopping 
could  be  relied  upon  for  preserving  the  walls  of  the  cavity  for 
one  or  two  years,  as  perfectly  as  it  does  for  a  few  months,  the 
caps  might  be  removed  and  a  solid  gold  filling  introduced,  with- 
out danger  of  causing  irritation  by  pressure  upon  the  bottom  of 
the  cavity.  He  further  adds,  that  he  "has  frequently  taken  out 
gold  fillings  of  his  own  insertion,  by  way  of  experiment,  which 
had  been  introduced  under  like  circumstances,  after  they  had 


FILLIXG   TEETH    OVER    EXPOSED    LINING   MEMBRANE.       315 

been  in  for  two  or  more  years,  and  on  removing  the  cap,  had 
found  the  bone  beneath  so  unyielding  and  void  of  sensibility, 
that  he  was  able  to  introduce  a  solid  gold  filling  without  the 
cap."  The  author  had,  in  1848,  a  case  (first  left  upper  molar) 
in  which  he  removed  a  suppurating  pulp,  and,  after  treating  for 
ten  days  with  injections  of  chlorinated  soda,  filled  the  cavity 
with  Hill's  stopping.  The  patient  was  requested  to  call  in  three 
weeks,  or  sooner  ;  but  put  it  ofi"  for  two  years.  On  removing  the 
temporary  filling  for  the  purpose  of  introducing  gold,  the  walls 
of  the  cavity  were  found  to  be  as  perfect  as  when  it  was  inserted. 

That  Dr.  Foster's  method  of  treatment  by  means  of  gutta 
percha  has  justified  the  expectations  which  he  many  years  ago 
formed  of  it,  may  be  inferred  from  the  following  extract  taken 
from  a  letter,  written  in  1863,  to  a  professional  friend.  The 
importance  of  the  subject  will,  it  is  hoped,  excuse  this  use  of  a 
letter  not  written  with  any  thought  of  publication : 

"I  would  I  could  speak  trumpet-tongued  to  the  members  of 
my  profession  upon  the  importance  of  an  expectant  course  of 
treatment  in  'preventing  exposure  of  the  nerve.  I  now  rarely 
expose  a  nerve  in  preparing  a  cavity.  If  there  has  been  neither 
inflammation  in  the  dental  pulp,  nor  pain  previously  to  the  ope- 
ration, I  avoid  cutting  too  deep  and  prepare  the  cavity  as  for  a 
gold  stopping.  But  if  I  consider  there  is  the  least  danger  of 
inflammation  from  the  pressure  of  the  gold  or  from  the  action  of 
heat  and  cold  through  the  metallic  medium,  I  invariably  pursue 
'  the  expectant  course  of  treatment. 

"  I  use  for  this  purpose  Hill's  stopping,  renewing  it,  if  neces- 
sary, until  all  local  irritation  has  ceased  and  the  interior  of  the 
cavity  has  attained  a  degree  of  hardness,  such  as  will  safely 
permit  the  insertion  of  a  solid  gold  filling.  This  usually  occupies 
a  year. 

"Fang  filling,  treatment  of  the  pulp,  of  abscess,  &c.,  all  de- 
mand our  most  serious  consideration.  But  still  more  important 
is  it  for  us  to  inquire  if  there  is  not  some  mode  of  treatment 
which  will  prevent  these  evils.  Hence  I  think  this  method  of 
prevention,  here  so  briefly  stated,  demands  the  most  careful 
attention  of  every  practitioner." 

The  method  pursued  by  the  author,  in  filling  a  tooth  after 
caries  has  penetrated  to  the  pulp-cavity,  is  a  very  simple  one. 


316       FILLING   TEETH    OVER    EXPOSED    LINING    MEMBRANE. 

The  caries  is  removed  and  the  cavity  prepared  in  the  usual  man- 
ner, using  the  precaution  not  to  wound  the  lining  membrane  if  it 
can  be  avoided ;  though  some  of  its  vessels  are  always  ruptured 
in  the  removal  of  the  last  layers  of  decomposed  dentine ;  then, 
the  cavity  is  wiped  out  very  carefully  with  a  dossil  of  cotton  satu- 
rated with  spirit  of  camphor,  which  immediately  arrests  the 
effusion  of  blood.  The  gold  is  next  introduced,  commencing  by 
placing  the  folds  on  one  side  of  the  cavity,  and  inserting  fold 
after  fold,  without  carrying  to  the  bottom  of  the  cavity  those 
immediately  over  the  exposed  part  of  the  lining  membrane  or 
pulp ;  thus  every  part,  except  a  very  small  space  immediately 
over  the  nerve,  is  thoroughly  filled.  The  folds  are  forced  so 
tightly  one  against  the  other,  as  to  prevent,  in  the  consolidation 
of  the  outer  extremities  of  the  folds,  the  liability  of  pressing 
their  inner  extremities  against  the  exposed  pulp  at  the  bottom 
of  the  cavity.  After  the  gold  has  been  thoroughly  condensed, 
the  surface  of  the  filling  is  finished  in  the  usual  manner. 

The  author  has  occasionally  placed  a  drop  of  the  solution  of 
gutta  percha  or  collodion  in  the  bottom  of  the  cavity,  waiting 
until  the  chloroform  had  completely  evaporated,  before  intro- 
ducing the  gold.  Dr.  Elliot,  of  Montreal,  states  in  an  article 
on  filling  teeth  over  exposed  nerves,  that  he  places  the  gold 
"  directly  upon  the  living  nerve,  and  in  perfect  contact  with  it, 
over  the  whole  of  its  exposed  surface,"  using,  when  the  cavity 
is  sufficiently  deep  to  admit  of  it,  asbestos,  a  non-conductor, 
^^ enveloped  in  a  few  thicknesses  of  gold  foil.''  He  also  says, 
that  within  the  last  year  he  had  but  two  cases  in  which  irritation 
advanced  so  far  as  to  become  troublesome  to  the  patient ;  and 
that,  in  both  instances,  perfect  and  permanent  relief  was  obtained 
by  the  use  of  leeches  and  a  mild  cathartic.  We  are  inclined  to 
believe,  however,  that  by  leaving  a  vacant  space  between  the 
filling  and  the  pulp,  the  success  of  the  operation  will  be  rendered 
more  certain.  The  result  of  the  operation,  however,  performed 
in  either  way,  cannot  always  be  immediately  ascertained.  Though 
it  may  at  first  be  apparently  successful,  suppuration  of  the  lining 
membrane  and  pulp  may  take  place,  three,  six,  or  even  twelve 
months  after  the  introduction  of  the  filling ;  hence  we  should 
not  decide  too  quickly  upon  the  results  of  any  given  treatment. 

Dr.  S.  P.  Ilullihen  described  to  the  author,  in  the  fall  of  1851, 


FILLING   TEETH    OVER    EXPOSED    LINING    MEMBRANE.       317 

a  method  which  he  had  recently  introduced  of  treating  teeth  after 
the  lining  membrane  had  become  exposed.  It  consists,  after 
filling  the  tooth  in  the  usual  way,  of  drilling  a  hole  with  a  small 
spear-pointed  drill,  about  a  line  above  the  edge  of  the  alveolus 
through  the  gum,  alveolar  wall  and  root  into  the  pulp-cavitj, 
using  the  precaution  not  to  separate  the  nerve,  and  wounding  it 
as  slightly  as  possible.  The  effused  lymph  resulting  from  the 
inflammation  occasioned  by  the  pressure  of  the  filling,  escapes 
through  this  opening ;  which,  he  believes,  when  the  increased 
vascular  action  subsides,  is  filled  with  callus,  and  ultimately  with 
dentine.  Dr.  Hullihen  informed  the  author  that  he  had  succeeded 
in  almost  every  instance  in  preserving  the  vitality  of  the  tooth. 
The  author  has  not  performed  the  operation  often  enough  to 
enable  him,  from  personal  experience,  to  express  an  opinion  as 
to  its  merits  ;  but  owing  to  frequent  failures  he  believes  that  it  is 
now  seldom  if  ever  performed. 

We  have  now,  without  going  into  detail,  given,  in  as  few  words 
as  possible,  all  the  information  we  possess  on  the  subject  of  filling 
teeth,  after  the  lining  membrane  has  become  exposed;  embracing 
the  result  of  our  experience  since  the  publication  of  the  fourth 
edition  of  this  work.  Our  confidence  in  the  utility  of  the  opera- 
tion, as  the  reader  may  perceive,  has  very  greatly  increased. 


CHAPTER    SIXTH. 
FILLING  PULP  CAVITIES  AND  BOOTS  OF  TEETH. 

Tins  operation  lias  now  become  very  common.  It  is  more  or 
less  practiced  by  many  dentists  in  America,  and  in  Europe, 
although  its  propriety  is  still  doubted  by  many.  The  objection 
to  the  practice  is  founded  upon  the  supposition,  that,  in  propor- 
tion as  the  vitality  of  a  tooth  is  lessened,  it  becomes  obnoxious 
to  the  surrounding  living  parts. 

It  is  contended  that,  though  the  presence  of  the  tooth  may 
not  give  rise  to  alveolar  abscess,  it  is  to  some  extent  a  local 
irritant;  that  as  such  it  must  necessarily  exert  a  morbid  influence, 
not  only  upon  the  living  parts  with  which  it  is  in  immediate  con- 
tact, but,  also,  upon  the  whole  economy.  Hence  it  is  argued, 
that  the  proper  remedial  indication,  after  the  death  of  the  lining 
membrane,  is  the  extraction  of  the  tooth.  This  reasoning,  it 
must  be  admitted  by  all  who  have  any  knowledge  of  the  laws  of 
health  and  disease,  is  not  without  much  seeming  plausibility. 
Until  within  a  comparatively  recent  period,  the  result  of  most 
of  the  efforts  made  for  the  preservation  and  retention  of  teeth  in 
this  condition,  fully  justified  its  supposed  correctness ;  for,  in 
nine  cases  out  of  ten,  the  operation  of  filling,  unless  an  opening 
was  left  for  the  escape  of  the  matter  secreted  at  the  extremities 
of  the  root,  was  followed,  sooner  or  later,  by  alveolar  abscess. 
The  conclusion,  therefore,  that  such  teeth  could  not  remain  in 
the  mouth  with  impunity,  was  a  very  natural  one.  But  more 
recent  experiments  have  shown  that  this  is  not  a  necessary  con- 
sequence. 

Drs.  Maynard  and  Baker  were  the  first  to  show  that  most  of 
the  morbid  phenomena  resulting  from  the  presence  of  a  tooth  in 
the  moutli  after  the  destruction  of  the  lining  membrane,  arose 
from  the  irritation  produced  by  the  matter  contained  in  the  pulp- 
cavity  and  canal  of  the  root.  To  prevent  their  occurrence,  there- 
fore, they  proposed  filling  both  cavity  and  canal  in  such  a  manner 


FILLING   PULP-CAVITIES    AXD    ROOTS    OF    TEETH. 


319 


as  completely  to  exclude  every  thing  else.  The  accumulation  of 
purulent  matter  being  prevented  here,  its  secretion  at  the  extre- 
mity of  the  root  will,  in  a  majority  of  cases,  either  cease  alto- 
gether, or  go  on  no  faster  than  it  is  reabsorbed,  as  has  been  shown 
by  repeated  experiments.  Thus  it  would  seem  that  the  amount 
of  vitality  which  a  tooth  derives  from  the  investing  membrane  is 
sufficient,  ordinarily,  to  prevent  it  from  exerting  any  apparent 
morbid  action  upon  the  surrounding  parts. 

Although  it  is  desirable  that  the  operation  should  be  per- 
formed before  any  diseased  action  has  been  set  up  at  the 
extremity  of  the  root,  much  advantage  may  sometimes  be  derived 
from  it  even  after  alveolar  abscess  has  actually  occurred.  Dr. 
Maynard  informed  the  author,  that  he  had  succeeded  in  curing 
the  disease  by  it.  Other  dentists  have  also  done  it,  and  the 
author  has  certainly  known,  in  several  instances,  great  benefit 
result  from  cleansing  and  filling  the  roots  of  teeth  which  had 
given  rise  to  abscess.  The  discharge  of  matter  has,  in  most  cases, 
on  which  he  has  operated,  been  greatly  diminished ;  often  subsid- 
ing altogether  for  several  months  at  a  time,  the  recurrence  rarely 
occasioning  much  inconvenience,  or  continuing  for  more  than  a 
week  or  ten  days.  Still,  he  does  not  feel  warranted,  from  his 
own  observations  and  experience,  in  recommending  the  operation 
in  cases  of  this  sort,  unless  the  preservation  of  the  tooth  is  called 
for  by  some  peculiar  necessity. 

During  the  year  1849,  Dr.  J.  H.  Foster  filled  the  pulp-cavities 
and  roots  of  forty  teeth,  with  the  following  results : 


Superior  molars. 

Inferior  molar,  (inflamed,) 

No  Abscess. 
2 
1 

Abscess. 
1 

Successfal. 

3 
1 

Unsuccesp 

Superior  bicuspids,  . 
Inferior         do. 

8 

2 

1 

2 

8 
4 

1 

Superior  cuspids, 
Inferior         do. 

6 
1 

1 
1 

7 
1 

1 

Superior  incisors,     . 
Inferior         do. 

12 
1 

1 

13 
1 

33 


38 


In  the  case  of  the  superior  bicuspid,  marked   unsuccessful, 


320  FILLING    PULP-CAVITIES   AND    ROOTS    OF    TEETH. 

■  Dr.  Foster  says,  the  patient  would  not  submit  to  the  pain,  and 
insisted  upon  the  removal  of  the  tooth  during  the  incipient  stage 
of  alveolar  abscess.  In  that  of  the  superior  cuspid,  the  abscess 
did  not  form  until  some  months  after  the  operation.  It  was 
opened  in  due  time,  but  as  the  parts  still  continued  painful,  an 
attempt  was  made  to  remove  the  filling.  This  was  unsuccessful, 
and  as  the  pain  continued,  the  tooth,  which  he  had  filled  into  the 
root  from  a  cavity  in  the  labial  surface,  was  extracted.  The 
fang  was  of  an  unusual  length,  and  had  a  bold  lateral  curvature 
about  three-fourths  of  the  way  to  the  apex,  rendering  the  passage 
of  an  instrument  beyond  the  angle  impossible.  He  had,  how- 
ever, forced  the  first  piece  of  foil  a  little  beyond  this  curve, 
which  resisted  all  efforts  for  its  removal.  The  fang  beyond  this 
point  had  become  discolored  and  the  periosteum  inflamed. 

The  ap])lication  of  creosote  to  the  inner  walls  of  the  sac, 
introduced  through  the  canal  in  the  root,  previously  to  filling, 
has  been  recommended  as  one  of  the  most  certain  means  of  cure. 
It  was  first  recommended  by  Dr.  C.  W.  Ballard,  and  has  been  tried 
by  the  author  with  very  gratifying  results.  It  is  introduced  on 
the  end  of  a  thread  of  waxed  floss  silk  to  the  sac  at  the  extremity 
of  the  root,  through  the  pulp  cavity  and  canal  of  the  fang,  pre- 
viously freed  of  all  extraneous  matter.  Another,  and  in  some 
respects  a  better  mode  of  applying  this  agent  to  the  ulcerated 
inner  surface  of  the  sac,  recommended  by  Dr.  F.  H.  Badger,  is 
to  throw  it  into  the  tooth  with  a  syringe,  the  opening  in  the 
crown  being  first  closed  with  a  piece  of  caoutchouc,  with  a  per- 
foration large  enough  to  admit  the  tube  of  the  instrument.  The 
creosote  is  used  in  the  form  of  a  strong  alcoholic  solution,  say 
one  drachm  of  creosote  to  an  ounce  of  alcohol.  This  being  for- 
cibly  injected  into  the  tooth,  passes  through  the  sac  at  the  end 
of  the  root  and  escapes  through  the  fistulous  opening  in  the 
gum,  where  it  is  caught  in  a  piece  of  soft  sponge  or  a  few  folds 
of  bibulous  paper.  There  are  many  cases  in  which  there  is 
simply  a  slight  morbid  secretion  that  escapes  through  the  tooth 
without  any  discharge  from  the  gums  The  means  most  effica- 
cious in  arresting  this  are  the  same  as  those  recommended  for 
the  treatment  of  abscess  of  the  socket;  the  creosote,  in  this  case, 
should  be  introduced  in  the  manner  as  first  described. 

Dr.  E.  J.  Dunning  stated  in  a  letter  to  the  author,  in  1850, 


FILLING    PULP-CAVITIES    AND    ROOTS    OF    TEETH.  321 

that  he  had  been  for  several  years,  and  was  then  constantly  in 
the  habit  of  filling,  the  fangs  of  teeth  after  destroying  their 
nerves,  and  also  of  cleansing  and  filling  the  fangs  of  teeth  which 
had  previously  lost  the  entire  pulp  and  become  more  or  less  dis- 

sed.  He  also  stated  that  very  few  cases  had  occurred  in 
actice  where  suppuration  had  supervened,  rendering  the 
1  of  the  tooth  necessary.  He  furthermore  remarks,  that 
whenever  the  investing  membrane  and  gums  of  teeth,  treated  in 
this  manner,  become  thickened  and  swollen,  the  symptoms  are 
less  severe.  In  proof  of  the  correctness  of  this  opinion,  he  has 
furnished  the  author  with  the  following  details  of  a  case  which 
came  under  his  observation. 

"  A  gentleman  from  the  south  called  immediately  after  his 
arrival  in  this  city,  and  stated  that  during  his  passage  in  the 
steamer,  he  had  been  suflfering  intensely  from  pain  in  a  first 
superior  molar.  On  examination  I  found  the  tooth  thoroughly 
injected  with  red  blood  and  the  periosteum  highly  inflamed  and 
considerably  thickened,  though  there  was  no  swelling  of  the 
gum.  A  small  cavity  in  the  posterior  approximal  surface  had 
been  filled  with  gold  a  day  or  tAvo  before  sailing.  In  preparing 
the  cavity  for  filling,  arsenic  had  been  used  to  allay  sensibility. 
In  most  cases  I  should  have  advised  the  removal  of  the  tooth, 
for  the  symptoms  were  very  unfavorable  to  any  operation  for 
its  preservation.  But  as  the  mouth  was  otherwise  perfectly 
healthy,  the  arch  unbroken,  the  cavity  in  the  tooth  very  small, 
and  the  patient  extremely  anxious  to  preserve  it,  I  determined 
to  make  the  trial. 

"  On  examining  the  cavity  carefully,  I  found  that  the  nerve 
had  never  been  exposed :  the  arsenic  had  acted  upon  it  through 
the  circulation,  and  had  thus  produced  tliis  severe  inflammation. 
Having  removed  the  layer  of  sound  bone  that  covered  the  nerve, 
and  finding  it  quite  sensitive,  I  made  an  application  of  an  ex- 
ceedingly small  quantity  of  a  mixture  of  arsenic,  morphine,  and 
creosote,  and  covered  it  with  a  metallic  cap  or  arch,  to  prevent 
pressure,  followed  by  a  loose  filling  of  tin  foil.  The  pain  and 
much  of  the  soreness  were  immediately  relieved. 

"  Saw  the  patient  again  on  the  fourth  day — found  the  sore- 
ness entirely  gone — had  sufi'ered  pain  since  the  application  was 
made — injection  remained  the  same.     Found  the  part  of  the 


322  FILLING    PULP-CAVITIES   AND    ROOTS    OF    TEETH. 

pulp  contained  in  the  central  cavity  entirely  insensible — removed 
it ;  finding  the  portion  in  the  fangs  still  sensitive,  made  the 
same  application  at  the  entrance  of  each  canal  and  filled  the 
cavity  again  with  tin.  At  this  sitting  ventured  to  file  the  tooth 
so  as  to  increase  the  separation  between  it  and  the  second  molar. 
The  filed  surface  showed  the  injection  beautifully,  the  bone  ap- 
pearing a  bright  red,  and  the  line  at  the  junction  with  the  enamel 
very  distinct.  In  three  or  four  days  saw  the  patient  again,  and 
to  my  surprise  and  delight  found  that  the  injection  had  en- 
tirely disappeared,  and  the  tooth  almost  as  perfect  in  color  as 
any  of  its  neighbors.  The  nerve  w^as  then  removed  from  the 
fangs,  and  its  place  filled  with  gold,  and  at  a  subsequent  sitting 
the  external  cavity  Avas  filled.  As  three  months  have  elapsed 
since  the  operation  was  performed,  without  hearing  from  it, 
I  conclude  that  it  is  thus  far  successful." 

Other  cases  of  a  similar  character,  and  with  similar  results 
might  be  given.  The  injection  of  the  tooth  from  the  vessels  of 
the  lining  membrane  and  pulp,  is  of  frequent  occurrence  in  teeth 
to  which  arsenic  is  applied  for  the  purpose  of  merely  destroying 
the  sensibility  of  the  dentine.  At  the  first  meeting  of  the 
American  Society  of  Dental  Surgeons,  Dr.  Hayden  mentioned 
a  case  that  had  a  short  time  before  fallen  under  his  observation, 
and  several  others  were  cited  by  the  author  at  the  same  time. 
Since  then  he  has  met  with  numerous  cases  in  which  this  had 
occurred.  It  is  doubtless  the  result  of  increased  vascular  action, 
excited  in  the  lining  membrane  and  pulp  by  the  action  of  the 
arsenic,  and  it  proves  that  the  vessels  of  teeth,  under  certain 
circumstances,  are  capable  of  conveying  red  blood.  It  occurs, 
however,  much  more  frequently  in  the  teeth  of  young  than  in 
those  of  old  persons. 

With  regard  to  the  best  means  of  destroying  the  nerve,  or 
rather  the  pulp  of  a  tooth,  there  exists  much  diversity  of  opinion. 
Immediate  extirpation  with  an  instrument,  arsenic,  and  the 
actual  cautery,  are  those  most  frequently  employed,  and  each 
has  its  advocates. 

To  the  use  of  arsenic  and  all  similar  agents,  Dr.  Harwood,  of 
Boston,  is  strongly  opposed.  He  states,  in  a  letter  to  the  author, 
written  in  1850,  that  "they  cause  death  and  sloughing  in  the 
parts  to  which  they  are  more  immediately  applied,  and  irritation 


FILLING    PULP-CAVITIES    AND    ROOTS    OF    TEETH.  323 

and  unmanageable  trouble  in  the  parts  next  beyond  those  they 
absolutely  kill.  In  other  words,  they  irritate  the  parts  beyond 
the  dental  cavity,  and  from  this  cause  (and  perhaps  from  chemi- 
cal injury  to  the  tooth  itself),  the  periosteum  of  the  root  and 
socket  becomes  the  seat  of  great,  and  frequently  of  uncontroll- 
able difficulty."  Entertaining  these  views,  he  regards  the  use 
of  such  means  as  opposed  both  to  experience  and  sound  philoso- 
phy ;  and  adopts,  without  knowing  that  the  same  thing  had  been 
done  by  others,  what  he  believes  to  be  a  more  correct  practice — 
immediate  extirpation.  He  thus. describes  his  method  of  accom- 
plishing this  object. 

"  I  first  effect  such  an  opening  as  will  enable  me  to  approach 
the  exposed  pulp,  in  the  line  of  its  axis,  or  as  nearly  so  as  cir- 
cumstances will  permit.  Then,  having  carefully  but  sufficiently 
exposed  the  surface  of  the  pulp,  I  pass  down  to  the  apex  of  the 
root,  through  the  pulp,  a  small  untempered  steel  instrument, 
with  a  trocar-shaped  point,  and  revolving  it  once  or  twice,  sever 
the  vessels  and  nerve.  This,  as  any  one  knows,  who  is  accus- 
tomed to  inserting  artificial  teeth,  produces  but  a  slight  and 
momentary  pain.  I  then,  by  means  of  minute  instruments, 
adapted  to  the  purpose,  endeavor  to  remove  every  portion  of  the 
severed  pulp  and  lining  membrane,  and  as  soon  as  the  hemor- 
rhage ceases,  dry  and  .fill  the  cavity. 

"  I  have  sometimes  only  filled  the  canal  at  the  first  sitting — 
leaving  the  body  of  the  tooth  to  be  treated  after  a  few  days. 
This  course  has  been  adopted  from  a  fear  that  the  pressure 
necessary  to  complete  the  whole  operation  might  enhance  the 
danger  of  inflammation  and  suppuration."  This  is  prudent,  but 
experience  does  not  convince  me  that  it  is  necessary. 

"  It  should  be  borne  in  mind,  that  at  the  point  where  the 
vessels  and  nerve  in  question  enter  the  root,  the  passage  is  much 
smaller  than  it  is  immediately  within.  This  strait  will  be  easily 
recognized  when  reached,  by  the  touch,  the  instrument  appearing 
to  be  arrested  by  an  obstacle,  and  not  by  being  wedged  in  a 
narrow  passage.  Care  should  be  taken,  I  think,  that  the  instru- 
ment is  not  allowed  to  pass  through  the  strait,  either  by  being 
too  small,  or  by  being  revolved  there  till  it  cuts  its  way  through. 
For,  by  wounding  the  parts  without  the  tooth,  and  forcing  par- 


324  FILLING   PULP-CAVITIES   AND   ROOTS    OF    TEETH. 

tides  of  bone  out  upon  the  parts  external  to  the  root,  the  danger 
of  an  unfavorable  result  would  be  greatly  increased." 

Dr.  Harwood  adds,  in  conclusion,  that  he  believes  it  is  better 
to  make  the  division  of  the  parts  a  little  within  the  strait,  though 
he  does  not  regard  the  matter  as  being  yet  fully  settled  by  ob- 
servation and  experience.  As  to  the  success  of  the  practice,  he 
speaks  very  confidently ;  not  having  had  a  case  treated  in  this 
manner,  where  the  patient  and  pulp  were  healthy,  in  which  there 
has  been  a  single  symptom  of  alveolar  abscess. 

In  a  paper  read  before  the  American  Society  of  Dental  Sur- 
geons, at  the  meeting  held  in  the  city  of  New  York,  August, 
1845,  and  published  in  the  sixth  volume  of  the  American  Journal 
of  Dental  Science,  p.  15,  Dr.  E.  J.  Dunning  maintains  very 
similar  views  with  regard  to  the  means  most  proper  to  be  em- 
ployed for  the  destruction  of  the  pulp  of  a  tooth.     He  says, 

"  The  destruction  of  the  nerve  by  mechanical  means  has  been 
practiced  to  a  small  extent  by  dental  surgeons  for  many  years ; 
but  on  account  of  the  severe  pain  which  in  many  cases  attends 
it,  as  well  as  from  the  fact  that,  in  the  manner  in  w^hich  it  has 
generally  been  practiced,  it  has  proved  no  more  successful  than 
other  and  less  severe  methods ;  it  has  been  considered  rather  in 
the  light  of  a  dernier  resort.''  This  he  believes  to  be  owing  to 
the  fact,  that  the  nerve  is  often  only  punctured  and  lacerated, 
and  afterwards  shut  up  in  the  tooth  and  left  to  decompose.  To 
prevent  which,  he  says,  the  whole  nerve  should  be  removed, 
and  its  place  filled  with  gold  or  tin  foil. 

Again,  Dr.  Dunning  remarks :  "  The  instrument  which  I  have 
used  to  excavate  the  fangs,  is  a  delicate  probe  of  steel,  perfectly 
annealed.  The  point  should  be  converted  into  a  very  slight 
hook,  and  made  sharp,  so  as  to  bring  away  the  nerve  or  other 
matter  with  which  the  cavity  may  be  filled.  For  the  removal  of 
the  nerve  in  the  chamber  of  the  crown,  in  molar  teeth,  as  well 
as  for  enlarging  the  cavity,  so  as  to  give  free  access  to  each  of 
the  fangs,  a  burr-drill  is  very  useful.  As  these  teeth  are  gene- 
rally very  much  decayed,  it  will  be  found  advisable,  when  the 
cavity  is  on  the  side  of  the  crown,  to  remove  its  edges  in  such  a 
manner  as  to  admit  the  light  directly  upon  the  openings  of  the 
fangs.  This  will  facilitate  the  operation  very  much,  and  at  the 
same  time  give   strength  to  the  walls  that  are  to  contain  the 


FILLING    PULP-CAVITIES    AND    ROOTS    OF    TEETH.  325 

Stopping."  When  the  nerve  has  been  destroyed  in  the  manner 
above  described,  Dr.  Dunning  says  that  the  operation,  so  far 
as  he  has  been  able  to  observe,  has  been  successful  in  every  case. 

On  the  different  methods  of  destroying  the  nerve,  Dr.  J.  H. 
Foster  says:  "It  is  a  difficult  matter,  and  I  have  generally 
found  it  utterly  futile  to  attempt  to  induce  patients  to  submit  to 
the  removal  of  the  pulp  by  extraction  or  excision  with  instru- 
ments, in  those  cases  in  which  it  becomes  necessary  to  destroy 
vitality  before  the  teeth  can  be  filled.  To  obtain  the  consent  of 
the  patient  by  a  representation  of  the  advantages,  in  its  imme- 
diate effects,  of  this  mode  of  treatment  by  extirpation,  as  con- 
trasted with  the  more  slow  and  uncertain  practice,  by  the  aid  of 
chemical  agents,  has  been  my  earnest  endeavor.  I  do  not  re- 
member a  single  case  of  the  removal  of  the  dental  pulp  by  an 
instrument — the  gold  being  inserted  into  the  dental  cavity 
immediately  after  the  hemorrhage  has  been  checked — which  has 
resulted  in  alveolar  abscess." 

Dr.  Foster,  however,  generally  employs  arsenious  acid,  with 
sulphate  of  morphia,  one  part  of  the  former  to  four  of  the  latter, 
applied  on  a  small  pellet  moistened  with  creosote.  After  apply- 
ing this  directly  over  the  nerve,  he  covers  it  with  a  cap,  to  avoid 
pressure ;  then  fills  the  external  cavity  with  some  soft  material 
which  will  exclude  moisture.  At  the  end  of  forty-eight  hours 
he  enlarges  the  dental  cavity,  removing  its  contents  to  the  apex 
of  the  root;  then,  after  waiting  another  forty-eight  hours,  he 
proceeds  to  fill  the  canal,  leaving  the  cavity  in  the  crown  to  be 
filled  at  a  subsequent  sitting.  * 

In  performing  this  operation  on  molar  teeth,  where  there  is 
a  probable  chance  of  a  favorable  issue,  and  the  preservation  of 
these  teeth  is  particularly  called  for,  he  thinks  it  important  that 
the  excavation  should  be  done  at  intervals,  so  as  to  cause  as 
little  irritation  at  each  sitting  as  possible,  and  that  the  filling  of 
the  different  cavities  in  the  tooth  be  also  proceeded  with  in  like 
manner. 

Dr.  Maynard — who  has  been  as  successful  in  filling  the  pulp- 
cavity  and  roots  of  teeth  as  any  other  practitioner,  and  has 
probably  had  more  experience,  having  been  in  the  habit  of  per- 
forming the  operation  since  1838 — having  thoroughly  tested  the 
method  of  destroying  the  nerve  by  immediate  extirpation  with 


326  FILLING    PULP-CAVITIES    AND    ROOTS    OF    TEETH. 

an  instrument,  as  well  as  that  by  the  application  of  arsenious 
acid,  gives  the  preference  to  the  latter.  His  method,  as  described 
by  Dr.  Wcstcott  in  a^oI.  7,  p.  286,  of  the  American  Journal  of 
Dental  Science,  is  as  follows: 

He  takes  white  wax,  and  works  it  into  cotton  or  lint  till  it  is 
thoroughly  mixed  together.  With  this  he  fills  the  cavities  in 
the  tooth.  But,  before  doing  this,  he  exposes  the  nerve  as  much 
as  possible,  applies  the  arsenic,  and  caps  the  orifice  with  a  cup- 
shaped  plate  of  lead,  the  convex  side  outwards.  While  this  is 
carefully  kept  in  place,  he  fills  the  cavity  with  the  cotton  and 
wax,  very  carefully  and  perfectly,  in  such  a  way  as  not  to  shut 
in  and  compress  any  air  which  might  press  upon  the  nerve. 
This  packing,  as  introduced  by  Dr.  Maynard,  will  keep  the 
"medicine,"  as  he  terms  it,  perfectly  dry  for  twenty-four  hours, 
or  longer. 

After  removing  this  packing  and  the  preparation,  he  pro- 
ceeds to  remove  the  nerve.  Instead  of  attempting  to  do  this  at 
once,  he  begins  by  cutting  on  every  side  of  the  orifice,  so  much 
enlarging  it  as  to  be  enabled  to  remove  the  nerve  without  press- 
ing the  contents  of  the  cavity  upwards. 

His  probes  are  objects  of  peculiar  interest,  especially  those 
for  extirpating  the  nerve.  Some  of  them  are  made  from  the 
main-spring  of  a  watch,  by  filing  or  grinding  them  sufficiently 
narrow,  to  enter  the  smallest  space  which  he  wished  to  probe. 
In  this  way  he  secures  the  most  perfect  spring  temper,  a  point 
not  easily  attained  in  so  frail  an  instrument  as  a  probe  adapted 
to  this  purpose.  These  prdbes  are  bearded  by  cutting  them  with 
a  sharp  knife — the  beard  pointing  backward.  With  dififerent 
sizes  of  these  and  other  probes,  and  by  enlarging  the  cavity 
from  time  to  time,  he  removes  the  nerve  to  the  extremity  of  the 
root. 

His  operation  of  filling  the  root  is  characterized  by  great 
neatness  and  dexterity.  His  instruments  are  of  the  most  deli- 
cate kind,  and  are  adapted  to  reach  to  the  end  of  the  fang, 
although  the  canal  may  not  be  entirely  straight.  In  filling 
these  roots  he  uses  very  heavy  gold,  we  believe  from  Nos.  12  to 
30.  This  is  cut  into  strips  corresponding  to  the  diameter  of  the 
cavity,  and  is  not  doubled.  The  end  of  one  of  the  strips  is  laid 
upon  the  end  of  one  of  his  delicate    pluggers,  and  carefully 


FILLING    PULP-CAVITIES    AND    ROOTS    OF    TEETH.  327 

carried  up  to  the  upper  extremity  of  the  root.  This  being  effected, 
the  instrument  is  withdrawn  a  slight  distance,  then  returned, 
carrying  Avith  it  another  portion,  till  the  strip  is  exhausted.  In 
this  way  the  whole  root  is  filled:  the  cavity  in  the  crown  is  then 
filled  in  the  usual  manner. 

Dr.  Arthur,  in  a  series  of  ably  written  articles,  published  in 
the  American  Journal  of  Dental  Science,  on  the  treatment  of 
caries  of  the  teeth,  complicated  with  disorders  of  the  pulp  and 
peridental  membrane,  recommends  the  use  of  cobalt  for  destroy- 
ing the  nerve  as  preferable  to  any  other  agent  or  means  that 
have  been  employed  for  the  purpose. 

In  the  destruction  of  the  pulp  of  a  tooth  the  author  has  em- 
ployed both  mechanical  and  chemical  agents.  He  has  been  in 
the  habit,  for  more  than  twenty  years,  of  occasionally  extirpat- 
ing the  pulp  to  the  extremity  of  the  root  by  introducing  a  very 
small  untempered  instrument,  with  a  spear-shaped  point ;  though 
not  at  first  with  the  view  of  afterwards  filling  the  pulp  cavity. 
He  has  also  used  the  actual  cautery  and  arsenious  acid.  To 
the  last  named  agent,  as  used  by  most  dentists  for  destrojung 
the  vitality  of  teeth,  he  was  at  one  time  strongly  opposed,  and 
still  believes  a  vast  amount  of  injury  is  produced  by  it;  but  with 
proper  care  and  judicious  after-treatment,  it  may  be  used  with 
safety,  and,  in  most  cases,  with  advantage.  He  now  employs  it 
for  destroying  the  vitality  of  the  lining  incmbrane  and  pulps  of 
the  molar  and  bicuspid  teeth,  and  occasionally  applies  it  to  the 
incisors  and  cuspids.  As  a  general  rule,  however,  when  he 
wishes  to  destroy  the  nerve  of  one  of  the  last  named  teeth,  he 
extirpates  it  by  thrusting  a  small  instrument  up  the  pulp  cavity 
to  the  extremity  of  the  root.  When  he  uses  arsenic,  he  applies 
about  the  thirtieth  or  fortieth  part  of  a  grain,  with  an  equal 
quantity  of  sulphate  of  morphia ;  placing  it  on  a  small  piece  of 
raw  cotton,  moistened  with  creosote  or  spirits  of  camphor,  and 
sealing  up  the  cavity  with  white  or  yellow  wax.  At  the  expira- 
tion of  seven  or  eight  hours,  ho  removes  the  wax  and  arsenic, 
and  afterward  the  pulp  of  the  tooth.  If  the  portion  in  the  root 
is  still  sensitive,  he  applies  it  a  second  time ;  but  he  seldom  finds 
it  necessary  to  do  so.  The  method  which  he  adopts  in  filling  the 
root,  or  roots  of  a  tooth,  is  the  same  as  that  pursued  by  Dr. 
Maynard. 


328  FILLING    PULP-CAVITIES    AND    ROOTS    OF    TEETH. 

It  sometimes  happens  that  the  canals  in  the  buccal  roots  of 
the  upper  molars  are  so  small  as  to  preclude  the  introduction 
even  of  a  small  sized  hog-bristle.  In  cases  of  this  sort,  it  is 
impossible  to  fill  them,  and  fortunately,  from  their  small  size, 
they  cannot  serve  as  reservoirs  for  the  accumulation  of  morbid 
matter.  The  canal  in  the  palatine  fang  is  always  much  larger 
than  in  either  of  the  buccal  roots,  and  in  a  majority  of  the  cases 
is  filled  with  comparative  ease. 

The  following  is  the  method  of  treatment,  preparatory  to  filling 
the  fang,  pursued  by  Professor  Gorgas,  of  the  Baltimore  College: 
"  I  remove  carefully  all  disorganized  pulp  and  decomposed  den- 
tine; also  all  discolored  dentine,  provided  it  does  not  weaken 
the  walls  of  the  cavity.  Then  syringing  out  all  loose  particles 
of  the  debris  with  tepid  water,  I  dry  the  canal  to  the  apex  of 
the  fang  with  floss  silk;  being  careful  to  leave  an  end  projecting 
so  as  to  permit  its  easy  removal.  Several  such  pieces  being  used, 
a  shorter  piece  is  then  saturated  with  creosote  and  passed  to  the 
end  of  the  canal,  leaving  a  slight  projecting  piece  in  the  pulp 
cavity,  so  that  it  may  be  seized  with  pliers  when  it  is  to  be 
removed. 

"  I  then  introduce  into  the  pulp  cavity  a  temporary  filling  of 
Hill's  stopping,  gutta-percha,  or  cotton  mixed  with  wax,  or  satu- 
rated with  sandarach  or  shell-lac  varnish.  In  twenty-four  hours 
the  canal  is  examined,  and  the  creosote  renewed  if  necessary. 
When  not  the  slightest  odor  of  purulent  secretion  is  perceptible, 
I  then  apply  on  the  floss  silk  chloroform  mixed  with  white  of  egg, 
replace  the  filling,  and  wait  for  several  days. 

"  If  at  the  end  of  this  time  there  is  no  trace  of  diseased  action, 
I  fill  the  canal  with  gold;  then  wait  a  few  days  until  all  chance 
of  irritation  from  the  pressure  used  in  the  operation  has  passed 
away,  and  then  complete  the  filling.  But  not  unfrequently  it  is 
necessary  to  repeat  this  course  of  treatment  several  times.  In 
one  case,  two  months  were  required  before  the  tooth  was  in  con- 
dition to  warrant  me  in  filling  it. 

"  In  some  cases  I  deem  it  prudlJnt  to  insert  a  filling  of  '  Hill's 
stopping,'  for  several  months,  especially  when  there  is  the 
slightest  doubt  of  the  arrest  of  the  disease;  for  the  gold  once 
introduced  into  the  canal,  it  is  exceedingly  tedious  and  diflicult 
to  remove  it.     Disease  on  the  outside  of  the  extremity  of  the 


FILLING    PULP-CAVITIES    AND    ROOTS    OF    TEETH.  329 

fang  may  be  controlled  by  creosote  and  nitrate  of  silver  applied 
through  the  fistulous  or  an  artificial  opening  in  the  alveolus. 

"  Chloride  of  zinc  may  be  used  instead  of  creosote  when  the 
smell  of  the  latter  is  particularly  repulsive  to  the  patient ;  and 
chlorinated  lime  or  soda  are  excellent  antiseptics.  Any  trace 
of  the  living  nerve  should  be  treated  with  arsenic,  a  minute 
portion  of  which  may  be  introduced  upon  floss  silk  before  com- 
mencing the  creosote  treatment." 

We  have  now  presented  a  condensed  summary  of  most  of  the 
information  we  possess  in  relation  to  the  operation  of  which  we 
are  now  treating.  Notwithstanding  the  favorable  light  in  which 
it  is  viewed  by  many  eminent  dentists,  we  think  it  should  be 
restricted  to  teeth,  the  presence  of  which  in  the  mouth  is  called 
for  by  some  peculiar  or  urgent  necessity.  It  is  only  in  such  cases 
that  we  advise  the  operation ;  for  occasional  unsuccessful  results 
have  attended  it,  in  the  practice  of  those  who  have  performed  it 
many  times;  which  proves  that  a  tooth,  after  the  destruction  of 
the  lining  membrane  and  pulp,  is  more  liable  to  give  rise  to  a 
diseased  action  in  the  socket,  than  a  tooth  not  deprived  of  these 
essential  constituents.  If  these  parts  did  not  perform  some 
necessary  function,  or  contribute  in  some  way  to  the  well-being 
of  the  tooth,  they  would  not  be  left  there ;  the  process  of  den- 
tinification  would  doubtless  be  carried  on  until  the  cavity  in 
which  they  are  contained  was  completely  obliterated.  Still,  as 
we  have  already  stated,  and  as  is  fully  proved  by  facts,  they  may 
often  be  removed  without  causing  a  tooth  to  exercise  any  imme- 
diate manifest  hurtful  action  upon  the  surrounding  parts  or  upon 
the  general  system. 

It  sometimes  happens,  where  the  central  cavity  has  been  filled 
for  a  length  of  time  with  black  purulent  matter,  that  the  crown 
of  a  tooth,  after  the  pulp  has  been  accidentally  deprived  of 
vitality  by  the  application  of  arsenic,  used  merely  with  a  view 
of  destroying  sensibility,  assumes  a  dark  brown,  and  sometimes 
almost  a  black  color:  this,  in  some  instances,  extends  to  every 
part  of  the  dentine  of  the  cro\^n;  in  such  cases,  it  is  important 
to  restore  the  natural  color  of  the  organ,  befor?  filling.  The 
agent  which  the  author  has  employed  for  this  purpose,  for  a 
number  of  years,  is  the  solution  of  chlorinated  soda.  After 
freeing  the  pulp  cavity  to  the  extremity  of  the  root  of  all  irapuri- 
22 


330  FILLING    PULP-CAVITIES   AND    ROOTS    OF    TEETH. 

ties,  and  removing  from  its  inner  walls  the  softened  or  decomposed 
portions  of  dentine,  he  fills  the  tooth  with  cotton,  saturated  with 
this  solution,  closing  the  orifice  with  white  wax,  and  permitting 
the  whole  to  remain  for  twenty-four  hours.  A  single  application 
will  sometimes  produce  the  desired  effect;  at  other  times  several 
are  necessary.  Dr.  Dwindle  has  used  sucessfully,  for  the  same 
purpose,  a  solution  of  lime,  probably  the  chlorinated.  The 
chlorine,  in  both  the  lime  and  the  soda,  is  powerfully  antiseptic 
and  decolorizing. 


CHAPTER    SEVENTH. 

FILLING  TEETH  WITH  CRYSTALLINE  OR  SPONGE  GOLD. 

Two  preparations  of  gold  for  filling  teeth  have,  within  the 
last  few  years,  been  brought  to  the  notice  of  the  dental  profes- 
sion, each  differing  somewhat  in  appearance  and  in  properties, 
and  both  widely  differing  from  foil  or  leaf  gold.  Each  has  a 
spongy  texture  and  appearance,  but  one  is  composed  of  crystals, 
and  the  other  of  small  granular  particles.  The  former  is  more 
readily  compressed  into  a  solid  mass,  and  hence  has  been  found 
better  adapted  for  filling  teeth.  But  in  the  use  of  either  of 
these  preparations,  a  different  method  of  procedure  is  required 
from  that  employed  with  foil;  the  instruments  necessary  to 
make  a  filling  with  the  one,  are,  in  many  cases,  unsuited  for 
operating  with  the  other.  A  separate  description  of  the  series 
of  manipulations  is,  therefore,  deemed  necessary. 

INSTRUMENTS  EMPLOYED  IN  THE  OPERATION. 

The  chief  difference  between  the  instruments  employed  for 
introducing  and  consolidating  these  preparations  of  gold  in  the 
cavity  of  a  tooth,  and  those  used  for  foil,  consists  mainly  in 
having  the  working  extremity  blunt,  varying  in  diameter  from  a 
line  to  a  mere  point,  with  cross  cuts  upon  the  surface,  giving  it 
a  sharp  denticulated  appearance.  Some  original  forms  of  instru- 
ments have  been  invented,  but  most  of  those  used  at  present  are 
mere  modifications  of  instruments  heretofore  employed  for  filling 
teeth  with  gold  foil.* 

*  A  series  of  the  most  approved  forms  that  have  been  devised  for  the  purpose,  are 
represented  in  an  article  by  Dr.  W.  H.  Dwinelle,  published  in  the  April  No.  of  vol.  5, 
New  Series,  of  the  American  Journal  of  Dental  Science.  Most  of  the  cuts  in  this 
chapter  are  copied  from  them. 


332 


INSTRUMENTS    EMPLOYED    IN    FILLING   TEETH. 


Fig.  120. 


Fig.  121. 


Fity.  120  represents  an  instrument  with  a  round  point,  flat  on 
one  side  and  slightly  convex  on  the  other.  It  is 
used  chiefly  for  carrying  small  masses  of  gold 
into  the  cavity  and  pressing  them  there.  It  is  a 
convenient  and  useful  instrument  and  cannot  well 
he  dispensed  with  in  working  these  preparations  of 
gold.  Several  sizes  are  required ;  the  pattern  was 
designed  by  Dr.  W.  M.  Hunter. 

An  instrument  somewhat  similar  to  the  foregoing 
is  represented  in  Fig.  121.     The  point,  instead  of 
being  round  or  circular,  is  oval,  bent  to  a  greater  angle,  with  a 

slight  oval  on  each  side.     It  is  in- 
tended more  particularly  for  carrying 
and  compressing  small  masses  of  gold 
in  cavities  on  the  approximal  surfaces 
of  teeth  slightly  separated  from  each 
other.     It  is  better  adapted  for  this 
purpose  than  any  instrument  at  pre- 
sent used.     Several  sizes  are  needed. 
The  working  extremities  of  all  in- 
struments   that    are    used    for    filling 
teeth  with   these  preparations  of  gold,  are   cross  cut,  forming 
upon  them  numerous  fine  sharp  points. 

Fig.  122  represents  an  instrument  slightly  bent  at  the  work- 
ing extremity,  the  upper  surface  flat,  and  terminating  in  a  blunt 
Fig.  122.  Fig.  123.  Fig.  124.  poi^t.  It  is  designed  chiefly  for  intro- 
ducing and  compressing  the  gold  in  the 
grinding  surface  of  molar  teeth,  both  of 
the  upper  and  lower  jaws.  Fig.  123 
represents  two  views  of  an  instrument 
having  the  general  form  of  the  one  last 
described,  but  filed  out  on  the  under  sur- 
face, the  point  being  prominent ;  it  is 
intended  to  be  introduced  a  short  dis- 
tance into  cavities  in  the  posterior  approximal  surface  of  molar 
and  bicuspid  teeth.  It  is  one  which  may  be  advantageously 
employed  in  many  cases.  Several  sizes,  both  of  this  and  the 
preceding  one,  are  required,  with  slight  modifications  of  form. 
The  instrument  represented  in  Fig.  124  is  designed  for  intro- 


INSTRUMENTS    EMPLOYED    IN    FILLING   TEETH. 


333 


Fig.  125. 


Fig.  126. 


ducing  gold  in  cavities  in  the  approximal  surfaces  of  incisor  and 
cuspid  teeth,  for  which  purpose  it  is  peculiarly  adapted. 

The  instruments  represented  in  Fig.  125,  contrived  by  Dr. 
Arthur,  are  said  to  be  very  useful  in  filling 
cavities  in  the  approximal  surfaces  of 
teeth ;  judging  from  their  appearance,  we 
have  no  doubt  they  may  be  advantageously  ■  ■  ^^ 
used  in  many  cases.  The  instrument  re- 
presented in  Fig.  126,  and  of  which  several 
are  required,  varying  in  size  and  bent  at 
different  angles,  is  chiefly  employed  in 
filling  cavities  in  the  approximal  surfaces. 
The  working  extremity  is  serrated.  This  is  done  in  either  of 
two  ways.  When  one  or  two  deep  serrations  are  required,  it  is 
best  done  with  a  small,  extremely  fine,  acute-angled  file.  When 
shallow  serrations,  or  a  number  of  them  (made  either  in  only  one 
direction  or  cross-cut),  are  required,  take  a  flat  single-cut  file, 
more  or  less  fine,  according  to  the  size  of  the  serrations  wanted  ; 
pass  the  point  of  the  plugger  eight  or  ten  times,  witli  a  steady 
movement,  across  the  file,  in  the  direction  of  the  cut.  By  turn- 
ing the  point  and  carrying  it  again  across  the  file,  at  right- 
angles  with  the  first  cut,  the  surface  is  dentated  with  rows  of 
sharp  points.  The  extreme  point  of  the  instrument  must  then 
be  made  as  hard  as  possible  (pale  straw  color),  short  of  brittle- 
ness ;  but  beyond  the  point  the  temper  may  be  more  elastic  and 
softer. 

Instruments  with  their  working  extremities  bent  at  various 
angles,  and  of  different  lengths  p,Q  ^27.  Fig.  128. 

and  sizes,  some  reduced  nearly 
to  a  sharp  point,  like  those 
represented  in  Figs.  127,  128, 
are  required  in  consolidating 
the  gold  in  cavities  of  the 
grinding,  approximal,  and  buc- 
cal surfaces.  The  points  may 
be  round  or  flat  as  the  operator  may  prefer.  Points,  also, 
much  smaller  than  the  smallest  here  represented,  bent  at  differ- 
ent angles,  are  needed. 


334 


INSTRUMENTS   EMPLOYED    IN   FILLING   TEETH. 


Fig.  129. 


Fig.  130. 


Fig.  129  represents  another  form  of  instrument  used  for  in- 
troducing and  partially  compressing 
gold  in  approxiraal  cavities.  The  work- 
ing extremities,  as  seen  in  the  cut, 
formino;  a  right-angle  with  the  stem  of 

O  o  O 

the  instrument,  should  vary  in  length 
and  diameter,  from  the  largest  here 
figured,  to  the  most  delicate  dimen- 
sions, so  as  to  be  made  available  in  the 
various  cases  in  which  their  use  may 
be  required. 
Another  instrument  with  working  points  somewhat  like  those 
shown  in  Fig.  129,  but  with  a  curved  stem,  is 
represented  in  Fig.  130.  When  bent  in  this 
way,  they  are  made  in  pairs,  one  for  the  right 
and  one  for  the  left  side,  and  should  be  of  dif- 
ferent sizes.  For  introducing  and  partially  con- 
densing gold  in  approximal  cavities  in  the  molar 
and  bicuspid  teeth,  they  are  peculiarly  well 
adapted.  The  author  has  a  set  made  from  pat- 
terns prepared  by  Dr.  Ballard,  of  New  York, 
which,  for  this  purpose,  he  has  found  more  serviceable  than  any 
other  description  of  instrument. 

The  instruments  in  Fig.  131  are  used  in  introducing  and  par- 
tially compressing  gold  in  anterior 
and  posterior  approximal  cavities  of 
molar  and  bicuspid  teeth.  Instru- 
ments of  this  description  have  been 
used  by  dentists  for  many  years  for 
condensing  gold  foil ;  but  they  may 
be  employed  more  advantageously  in 
working  crystalline  gold.  It  is  only, 
hoAvever,  in  the  earlier  stages  of  the 
operation  that  they  can  be  efficiently  used,  unless  the  working 
extremity  be  very  small. 

In  Figs.  132,  133  and  134  instruments  with  variously  shaped 
points  are  represented.  Some  of  them  are  mere  modifications 
of  those  previously  described.  But  in  the  use  of  crystalline  and 
sponge  gold  they  will  all  be  found  very  useful. 


Fig.  131. 


INTRODUCING    AND    CONSOLIDATING    THE    GOLD.  335 

Fig.  132.  Fig.  133.  Fig.  134. 


Other  forms  of  instruments  are  sometimes  employed  in  the 
use  of  sponge  gold,  but  those  here  represented  will  be  found 
amply  sufficient  for  all  operations,  and  hence  it  has  not  been 
deemed  necessary  to  give  a  more  extended  description. 


INTRODUCING  AND  CONSOLIDATING  THE  GOLD. 

In  filling  teeth  with  crystal  or  sponge  gold,  the  cavity  in  the 
tooth  is  prepared  in  the  same  manner  as  when  leaf  gold  is  em- 
ployed. This  done,  the  gold  is  cut,  or  rather  torn  with  the  point 
of  an  instrument,  into  small  pieces,  varying  in  size  according  to 
the  dimensions  of  the  cavity  and  the  particular  stage  of  the  ope- 
ration in  which  it  is  to  be  used.  It  being  important  that  the 
crystals  or  particles  composing  the  mass,  should  be  as  little 
separated  or  displaced  as  possible,  before  the  piece  is  carried  to 
its  place  in  the  tooth  ;  it  should  be  used  in  pellets  as  large  as  can 
be  introduced  into  the  cavity  without  crumbling. 

The  gold  being  divided  into  pieces  of  the  proper  size,  the 
cavity  is  washed,  and  then  wiped  dry  with  prepared  cotton,  flax 
or  bibulous  paper ;  a  piece  of  gold,  as  large  as  the  orifice  of  the 
cavity  will  receive,  is  taken  up  with  suitable  pliers  (Fig.  135)  or 

Fig.   135. 


one  of  the  instruments  represented  in  Figs.  120,  123,  as  may  be 
most  convenient.  The  spongy  mass  readily  adheres  to  the  ser- 
rated surface  of  the  working  extremity,  when  pressed  gently  upon 
it,  and  with  this  it  may,  in  most  cases,  be  carried  to  the  bottom 


336  INTRODUCING    AND    CONSOLIDATING    THE    GOLD. 

of  the  cavity.  Every  part  must  now  be  thoroughly  consolidated, 
first  with  a  large,  and  next  with  a  smaller,  and  lastly  with  a  very 
delicately  pointed  instrument,  so  bent  that  it  may  be  readily 
applied  to  all  the  depressions  and  inequalities  of  the  walls  and 
floor  of  the  cavity ;  for  unless  the  gold  is  made  absolutely  solid 
in  these  places,  as  well  as  throughout  all  the  parts  of  the  filling, 
the  success  of  the  operation  will  be  more  or  less  uncertain.  Thus, 
piece  after  piece  is  applied,  consolidating  each  one  as  the  opera- 
tion progresses,  until  the  gold  protrudes  sufficiently  from  the 
orifice  of  the  cavity  to  admit  of  a  good  finish,  leaving  the  surface 
flush  with  that  of  the  tooth. 

If,  during  any  part  of  the  operation,  the  smaller  pointed  in- 
struments can  be  forced  between  the  gold  and  the  walls  of  the 
cavity,  such  opening  or  openings  should  be  filled  with  smaller 
masses  of  the  material  before  another  large  piece  is  introduced. 
This  precaution  ought  never  to  be  neglected,  for  should  any  soft 
places  exist  after  the  completion  of  the  operation,  the  filling  will 
be  liable  to  absorb  moisture  and  ultimately  to  crumble  and  come 
out.  It  is  also  indispensably  necessary  that  the  gold,  during  its 
introduction  into  the  tooth,  be  kept  absolutely  free  from  moisture, 
as  this  destroys  the  adhesive  or  welding  property  of  the  crystals. 

The  gold  having  been  introduced  and  consolidated  as  directed, 
the  exposed  surface  is  scraped  or  filed  down  to  a  level  with  the 
orifice  of  the  cavity,  then  made  smooth  by  rubbing  it  with  Arkan- 
sas stone,  or  with  finely  powdered  pumice,  and  burnished  or  pol- 
ished with  crocus,  in  the  manner  as  described  when  gold  foil  is 
used. 

In  finishing  a  filling  made  with  these  preparations  of  gold,  the 
operator  should  see  that  there  are  no  thin  overlapping  portions 
upon  the  teeth  outside  of  the  orifice  of  the  cavity.  They  are 
liable,  in  biting  hard  substances,  or  in  ordinary  mastication,  to 
be  broken  ofi",  leaving  a  depression  for  the  lodgment  of  extrane- 
ous matter  and  clammy  secretions.  Sooner  or  later  this  will 
give  rise  to  a  softening  of  the  dentine  thus  exposed,  which,  if  it 
does  not  cause  the  filling  to  loosen,  will  ultimately  render  its  re- 
moval and  replacement  necessary.  In  short,  the  precautions 
necessary  to  be  observed  in  making  a  filling  with  gold  foil  are 
equally  necessary  when  the  operation  is  made  with  either  of  the 
preparations  now  under  consideration. 


INTRODUCING    AND    CONSOLIDATING    THE    GOLD.  337 

We  might  enlarge  upon  this  part  of  our  subject,  by  going  into 
detail  and  describing  the  various  manipulations  required  to  fill 
a  tooth  in  the  several  localities  in  which  the  operation  may  be 
called  for ;  but  the  foregoing  general  directions  will  serve  as  a 
suflBcient  guide  to  the  dentist  in  the  use  of  these  preparations  of 
gold.  For  a  fuller  exposition  of  the  subject,  the  reader  is  referred 
to  a  series  of  interesting  articles  by  Dr.  C.  W.  Ballard,  published 
in  the  March,  April,  May  and  June  numbers  for  1855,  of  the 
New  York  Dental  Recorder,  and  to  the  article,  by  Dr.  Dwinelle, 
previously  referred  to. 


CHAPTER    EIGHTH. 

BUILDING  ON  THE  WHOLE  OR  PART  OF  THE  CROWN 
OF  A  TOOTH. 

Feav  persons  have  the  patience  to  undergo  an  operation  re- 
quiring so  much  time  for  its  performance,  as  the  building  on  the 
whole,  or  a  large  part  of  the  crown  of  a  tooth,  and  fewer  still 
are  willing  to  incur  the  expense  of  the  labor  and  gold  necessary 
to  make  one.  Hence,  it  is  seldom  attempted,  and  can  only  be 
performed  by  the  most  expert  and  skillful  manipulators.  Pro- 
fessor Austen,  speaking  of  these  operations,  says :  "  The  ma- 
jority of  them  are  a  useless  waste  of  the  skill  of  the  dentist,  the 
money  of  the  patient  and  the  time  of  both.  A  molar  fang  that 
has  its  periosteum  injured  by  the  protracted  and  heavy  pressure 
required  in  building  up  a  golden  crown  is  in  far  worse  condition 
than  if  nothing  had  been  done.  If  simply  the  canals  and  re- 
maining part  of  the  pulp-cavity  had  been  filled,  the  root  would 
present  a  condition  analogous  to  those  cases  in  which  the  crown 
is  worn  off  (or,  it  may  be,  decayed  off)  and  the  pulp-cavity  filled 
by  ossific  deposit :  such  roots  render  valuable  service  for  many 
years.  An  incisor  tooth  which  carries  upon  half  or  one-third  of 
its  surface  a  golden  sign  of  dental  craft,  disfigures  the  patient ; 
shows  none  of  the  ars  celare  arteyn,  which  should  as  far  as  possible 
characterize  all  dental  work ;  and  has  a  very  questionable  per- 
manence or  utility."  Nevertheless,  as  these  operations  are 
sometimes  done,  it  would  not  be  proper  to  omit  a  description 
of  the  manner  of  doing  them. 

It  is  scarcely  to  be  expected,  however,  that  any  one  who  has 
not  had  considerable  experience  in  filling  teeth,  and  acquired  a 
high  degree  of  dexterity  in  the  use  of  instruments  and  the  work- 
ing of  some  one  or  more  of  the  preparations  of  gold  employed 
for  the  purpose,  will,  simply  from  any  directions  that  can  be  laid 
down  upon  the  subject,  be  able  at  once  to  perform  the  operation. 
But  it  is  hoped,  that  the  following  description  may  serve  as  a 


BUILDING    ON    THE    CROWN    OF    A    TOOTH.  339 

guide  to  tliose  who  have  never  attempted  it  and  may  wish  to 
exercise  their  mechanical  and  artistic  abilities  on  this,  the  most 
difficult  of  all  operations  in  dentistry.  Those  only  who  are  aim- 
ing at  high  excellence  in  this  department  of  practice,  will  be 
likely  to  undertake  it ;  and  should  their  first  eiforts  prove  unsuc- 
cessful, the  increase  of  skill  they  will  have  thus  acquired  in  the 
use  of  instruments,  will  inspire  new  confidence,  and  ultimately, 
by  perseverance,  enable  them  to  achieve  the  object  of  their  wishes. 

The  operation  to  be  successful  must  not  only  be  performed  in 
the  most  perfect  manner,  but  the  tooth  itself  must  be  situated  in 
a  healthy  socket  and  firmly  articulated.  Under  other  circum- 
stances it  would  be  useless  to  attempt  the  restoration  of  the 
organ.  The  general  system,  too,  should  be  free  from  any  ])re- 
ternatural  susceptibility  to  morbid  impressions. 

A  tooth  on  which  this  operation  is  called  for  has,  in  nearly 
every  case,  suffered  so  much  loss  of  substance  as  to  involve  ex- 
posure of  the  pulp  ;  consequently  the  destruction  and  removal  of 
this,  is  the  first  thing  to  be  attended  to ;  unless,  as  is  sometimes 
the  case,  it  has  previously  perished  from  inflammation  and  sup- 
puration. Where  this  has  happened,  the  permanent  preservation 
of  the  organ  cannot  be  counted  on  with  as  much  certainty  as 
when  it  is  destroyed  by  the  application  of  an  escharotic  two  or 
three  days  before  the  performance  of  the  operation.  Its  destruc- 
tion by  the  suppurative  process  is  more  apt  to  be  followed  by 
alveolar  abscess ;  and  this  having  once  established  itself,  is  sel- 
dom so  completely  cured  as  to  prevent  the  liability  to  its  recur- 
rence. Still,  if  the  operation  is  determined  on,  the  parts  of  the 
extremity  of  the  root  must  first  be  restored  to  health  ;  for  with- 
out this  it  should  never  be  attempted.  The  preparatory  treat- 
ment in  cases  of  this  sort,  as  well  as  in  cases  of  simple  morbid 
secretion  escaping  from  the  fang,  is  given  in  another  chapter. 

In  describing  the  operation,  we  will  commence  with  the  first 
molar  of  the  left  side  of  the  superior  maxilla.  We  will  suppose 
that  about  three-fourths  of  the  crown  has  been  destroyed  by 
caries,  and  that  the  buccal  wall  is  the  only  portion  remaining, 
the  pulp  being  more  or  less  exposed.  This  is  to  be  destroyed 
and  extirpated  to  the  extremity  of  each  root ;  the  decayed  por- 
tions of  the  tooth  are  then  to  be  removed,  and  the  central  cham- 
ber enlarged  until  the  wall  of  dentine  on  the  palatine,  anterior 


340        BUILDING  OX  THE  CROWN  OF  A  TOOTH. 

and  posterior  approximal  sides  are  only  about  one  line  in  thick- 
ness. On  the  inside  of  this  wall,  a  shallow  groove  or  undercut 
is  made  to  give  additional  security  to  the  gold. 

The  tooth  as  now  prepared  is  represented  in  Fig.  136,  and  is 
ready  for  the  introduction  and  building  on  of  the 
gold.  But  before  describing  the  manner  of  doing 
this,  it  may  be  well  to  say  a  few  words  with  re- 
gard to  the  preparation  of  gold  most  proper  to  be 
employed.  For  filling  the  roots,  the  foil  ordinarily 
used  is  the  best.  If  the  leaves  are  thick,  weigh- 
ing from  fifteen  to  twenty  grains,  it  should  be  in- 
troduced in  very  narrow  strips,  without  folding, 
in  the  manner  described  in  another  chapter ;  if 
leaves  of  four  or  six  grains  are  preferred,  it  may  be  cut  in  strips 
varying  from  an  eighth  to  a  quarter  of  an  inch  in  width,  accord- 
ing to  the  size  of  the  canal  in  the  root,  and  then  rolled  or  made 
into  very  narrow  folds.  For  the  central  chamber  and  crown, 
gold  possessing  adhesive  properties  should  be  employed ;  this 
property  may  be  imparted  to  common  gold  foil  by  slightly  an- 
nealing immediately  before  using ;  foil  made  from  crystalline 
gold  possesses  it  in  a  higher  degree,  but  this  also  requires  to  be 
annealed.  Either  kind  of  foil,  therefore,  or  crystalline  gold 
itself  may  be  employed.  The  operation,  however,  can  be  made 
with  less  labor  with  either  of  the  first  two,  than  with  the  last 
named  preparation. 

The  manner  of  filling  roots  having  been  before  described,  we 
shall  commence  with  the  pulp-cavity.  The  gold,  supposing  it  to 
be  foil  No.  4,  is  cut,  each  leaf  into  four  or  six  pieces,  which  are 
loosely  rolled  into  round  or  oval  pellets.  A  sufficient  number 
of  these  having  been  prepared,  the  surfaces  against  which  the 
gold  is  to  be  placed  are  made  perfectly  dry  by  wiping  with  bibu- 
lous paper,  flax  or  cotton.  This  done,  one  of  the  pellets  or  balls 
is  placed  in  the  central  chamber  with  pliers,  and  partially  con- 
solidated with  a  small  pointed  condensing  instrument ;  another 
and  another  is  added,  each  being  consolidated  as  the  first ;  until  a 
suflBcient  number  have  been  introduced  to  obtain  so  firm  a  support 
from  the  surrounding  wall  of  dentine  as  to  prevent  any  portion  of 
the  filling  from  being  moved.  The  process  of  consolidation  is  now 
to  be  repeated  and  continued,  until  no  part  of  the  gold  can  be 


BUILDING    ON    THE    CROWN    OF    A    TOOTH.  341 

made  to  yield  to  the  pressure  of  the  instrument ;  then  additional 
pellets  are  applied  and  condensed  as  in  the  first  instance,  until 
the  pulp-cavity  is  completely  filled  ;  forcing  those  placed  against 
the  surrounding  wall  firmly  and  compactly  into  the  groove  or 
undercut  made  in  it,  thus  securing  for  the  entire  mass  the  great- 
est possible  stability.  Again,  pellet  after  pellet  is  applied,  press- 
ing those  placed  along  the  outer  edge  firmly  against  the  exposed 
margin  of  dentine  and  against  the  buccal  wall  of  the  tooth  ;  until 
a  solid  mass,  considerably  larger  than  the  portion  of  the  crown 
to  be  supplied  shall  have  been  thus  formed. 

For  the  complete  solidification  of  every  part  of  the  gold,  and 
the  welding  of  every  piece  to  the  adjoining  ones,  a  number  of 
instruments  are  required,  with  serrated  points,  varying  in  size 
from  the  one  in  Fig.  110  to  less  than  half  the  size  of  the  one  in 
Fig.  107.  For  some  parts  of  the  operation  a  straight  instrument 
can  be  employed  most  advantageously ;  for  other  parts  one 
slightly  bent  near  the  point,  and  for  others  one  bent  at  right 
angles  with  the  stem :  the  kind  most  suitable  for  each  case  must 
be  determined  by  the  judgment  of  the  operator.  One,  perhaps, 
may  use  very  efiiciently  an  instrument  in  a  particular  locality 
and  for  a  certain  purpose,  that  another  for  the  same  purpose 
would  handle  very  awkwardly.  But  for  completing  the  work  of 
consolidation,  all  agree  that  very  small  pointed  instruments  are 
indispensable. 

As  the  adhesiveness  of  the  gold  is  destroyed  by  the  contact 
of  liquids,  it  must  be  kept  absolutely  free  from  moisture  during 
the  entire  process  of  introducing  and  consolidating  the  metal. 
But  if,  notwithstanding  every  precaution,  the  saliva  should  come 
in  contact  with  the  gold  before  its  complete  introduction,  the 
unfinished  surface  must  be  thoroughly  consolidated ;  then  dried 
with  some  good  absorbing  substance,  scraped,  V  nished,  dried 
again,  and  made  rough  with  a  sharp  pointed  instrument.  To 
this  surface  fresh  portions  of  gold  can  now  be  united,  and  made 
to  adhere  as  firmly  as  if  no  interruption  had  taken  place. 

The  next  step  is  to  consolidate  thoroughly  every  part  of  the 
surface.  This  may  be  commenced  with  the  larger  pointed  in- 
struments. After  going  over  it  ten  or  a  dozen  times  with  these, 
smaller  points  may  be  used,  and  these  again  changed  for  still 


342  BUILDING    ON    THE    CROWN    OF   A    TOOTH. 

smaller,  until  no  more  impression  can  be  made  upon  it  than 
upon  a  solid  ingot  of  pure  gold. 

It  now  remains  to  file  and  scrape  the  surface  until  the  gold  is 
made  to  assume  very  nearly  the  shape  of  that  portion  of  the 
original  tooth,  the  loss  of  Avhich  it  supplies.  In  doing  this  an 
opportunity  is  afforded  to  the  operator  for  the  display  of  much 
artistic  skill  and  ingenuity.  While  shaping  the  grinding  surface, 
the  patient  should  be  requested  from  time  to  time  to  close  the 
mouth ;  that  the  depressions  in  it  may  be  made  to  correspond  to 
the  cusps  of  the  tooth  with  which  it  antagonizes,  so  that  these 
two  may  touch  simultaneously  with  the  other  teeth  of  the  upper 
and  lower  jaws.  This  part  of  the  operation  is  always  tedious, 
usually  requiring  more  time  than  for  the  consolidation  of  the 
gold. 

The  surface  of  the  gold  may  now  be  rubbed  with  properly- 
shaped  pieces  of  Arkansas  or  Lake  Superior  stone,  or  with  pul- 
verized pumice,  until  all  the  scratches  left  by  the 

Fig    137 

file  are  removed ;  then  polished  with  crocus  or  a 

burnisher.     The  appearance  of  the  tooth  as  thus 
restored  is  shown  in  Ficr.  137. 

As  it  is  impossible  to  perform  the  entire  opera- 
tion at  one  time,  it  may  readily  be  divided  into 
three  parts.  The  first  consisting  in  the  extirpa- 
tion of  the  pulp  and  the  preparation  of  the  tooth; 
the  second,  in  the  introduction  and  solidification 
of  the  gold ;  the  third,  in  giving  to  the  metal  the  proper  con- 
formation and  in  finishing  the  surface.  The  time  required  for 
the  first,  supposing  the  operation  to  be  like  the  one  just  de- 
scribed, may  vary  from  one  and  a  half  to  two  and  a  half  hours ; 
for  the  second,  from  two  to  three  and  a  half  hours,  and  for  the 
third,  from  two  to  six  hours — according  to  the  diflBculties  to  be 
encountered,  the  ability  of  the  dentist,  and  the  completeness  of 
his  preparation  for  the  operation.  Some,  perhaps,  may  prefer 
crystalline  or  sponge  gold,  supposing  it  to  be  more  easily  welded 
than  adhesive  foil ;  but  as  the  manner  of  working  this  variety 
of  gold  has  already  been  dsecribed,  it  will  not  be  necessary  to 
give  additional  directions  for  its  use. 

The  operation  of  building  on  the  entire  crown  of  a  tooth 
should  be  proceeded  with  in  much  the  same  way  as  just  described 


BUILDING  ON  THE  CKOWX  OF  A  TOOTH.        343 

for  part  of  the  crown.  If  too  large  pieces  of  either  crystal  gold 
or  foil  are  used  at  one  time,  the  surface  will  become  crusted  over 
by  the  pressure  of  the  point  of  the  instrument,  and  this  will 
prevent,  by  any  subsequent  force  that  can  be  safely  applied,  its 
thorough  consolidation.  In  this  case,  the  general  mass  will  be 
more  or  less  spongy  and  the  operation  imperfect.  The  dentist 
should  be  well  assured,  therefore,  as  he  progresses  with  his  work, 
that  every  successive  layer  is  firmly  adherent  to  the  preceding 
one.  To  build  up  an  entire  crown  requires  more  time ;  perhaps, 
also,  more  skill,  as  there  is  no  wall  of  tooth  substance  to  give 
partial  support.  In  other  respects  it  resembles  the  previous 
operation. 

It  has  been  suggested  by  Professor  Austen,  as  a  plan  to  avoid 
much  of  the  tediousness  of  the  second  stage  of  this  operation, 
to  fill  the  pulp-cavity,  enclosing  in  the  centre  a  screw-cut, 
notched,  or  double-headed  pin,  and  carrying  the  gold  over  the 
edges  of  the  cavity ;  make  this  surface  somewhat  irregular  in 
shape,  but  finish  it  smoothly  and  trim  the  circumference  to  the 
exact  size  of  the  tooth ;  take  a  wax  or  plaster  impression  of  the 
surface,  and  fit  to  the  plaster  model  a  lump  of  gold,  having  in 
the  centre  a  hole  larger  than  the  pin  projecting  from  the  root ; 
shape  and  polish  it  out  of  the  mouth,  then  set  it  in  place  and 
secure  it  by  filling  with  gold  around  the  pin.  If  the  color  is  not 
objected  to,  a  vulcanite  crown  could  be  very  perfectly  adapted 
in  this  manner ;  or  a  porcelain  tooth  could  be  made,  hollow  in 
the  centre,  with  pins  or  a  dovetail  to  hold  a  thin  layer  of  vul- 
canite, by  means  of  which  it  could  be  fitted  with  perfect  accu- 
racy to  the  prepared  root.  Professor  Austen  thinks  that  in  this 
way  the  root  will  be  less  injured,  and  the  union  between  the  gold 
and  the  root  less  disturbed  than  by  the  long-continued  and  se- 
vere pressure  of  the  ordinary  operation.  While  the  artificial 
crown  is  being  made,  he  suggests  a  temporary  gutta-percha  crown 
to  prevent  any  irritation  from  the  projecting  pin. 

A  large  portion  of  the  crown  of  a  tooth  may  be  built  up  with 
ordinary  gold  foil,  if  it  be  of  the  best  quality ;  but  the  adhesive 
preparations,  either  foil  or  crystal  gold,  are  preferable.  It  is 
more  difficult  to  build  up  the  crown  of  a  tooth  in  the  lower  than 
in  the  upper  jaw,  owing  to  the  great  difficulty  of  controlling  the 
flow  of  saliva  during  so  long  an  operation. 


344  BUILDING    ON    THE    CROWN    OF   A    TOOTH. 

We  have  endeavored,  in  the  foregoing  description,  to  point 
out  the  general  method  of  procedure  in  the  operation  of  which 
we  have  been  treating.  We  have  also  noticed  some  of  the  pre- 
cautions necessary  to  be  observed;  but  unexpected  diflBculties 
are  sometimes  encountered,  the  peculiar  nature  of  which  it  is 
impossible  to  anticipate.  Few,  however,  are  of  so  formidable  a 
character  that  they  cannot  be  overcome.  "Only,"  says  Profes- 
sor Austen,  "let  the  operator  assure  himself  that  he  is  laboring 
for  the  real  benefit  of  his  patient,  and  not  degrading  his  art:  on 
the  one  hand,  by  humoring  an  idle  whim  of  his  patient;  or,  on 
the  other,  by  making  him  the  reluctant  advertising  medium  of 
dental  ingenuity." 


CHAPTER    NINTH. 
TOOTH-ACHE. 

Pain  in  a  tooth,  tootli-ache,  or  odontalgia,  as  it  is  technically 
termed,  is  a  symptom  of  some  functional  or  structural  disturb- 
ance ;  either  of  the  organ  in  which  the  pain  is  seated,  or  of  some 
other  part  or  parts  of  the  body,  but  more  frequently  of  the  for- 
mer than  of  the  latter.  So  variable  is  the  character  of  the 
sensation,  that  any  description  would  fail  to  convey,  to  one  who 
has  never  experienced  it,  a  correct  idea  of  its  nature.  The  pain 
sometimes  amounts  only  to  slight  uneasiness ;  at  other  times  the 
agony  is  almost  insupportable.  It  may  be  dull,  deep-seated, 
boring,  throbbing,  or  lancinating.  It  may  be  slight  at  first, 
gradually  increasing  in  severity  until  it  amounts  to  the  most  ex- 
cruciating torture,  or  it  may  come  on  without  any  premonition 
whatever.  It  may  be  confined  to  a  single  tooth,  or  it  may  affect 
several  at  the  same  time.  It  may  commence  in  one  tooth,  and 
pass  from  thence  to  another,  and  continue  until  every  one  in 
turn  has  been  attacked.  It  may  continue  for  hours  and  days 
with  scarcely  any  cessation;  or  it  may  be  intermittent,  the  par- 
oxysms recurring  at  stated  or  irregular  intervals,  and  each  last- 
ing from  thirty  minutes  to  one,  two,  or  more  hours. 

CAUSES. 

The  causes  of  tooth-ache  are  almost  as  numerous  as  are  the 
varieties  of  character  which  it  exhibits.  Irritation  and  inflam- 
mation of  the  pulp,  and  inflammation  of  the  investing  membrane 
are  among  the  most  frequent;  but  it  is  sometimes  referable  to 
a  morbid  condition  of  the  nerve  or  nerves  going  to  a  single  tooth, 
or  of  the  trunk  from  which  several  teeth  are  supplied ;  also  to 
derangement  of  the  digestive  organs,  to  increased  nervous  sus- 
ceptibility of  the  uterus  resulting  from  pregnancy,  amenorrhoea, 
&c.,  and  to  certain  diatheses  of  the  general  system. 
23 


346  CAUSES    OF   TOOTH-ACHE. 

Dr.  Hullihen  enumerates  the  following  as  the  causes  of  tooth- 
ache:  1,  exposure  of  the  nerve;  2,  fungus  of  the  nerve;  3, 
confinement  of  pus  in  the  internal  cavity;  4,  a  diseased  state 
of  the  periosteum  covering  the  fang;  and  5,  sympathy.  Dr. 
Heildcn  attributes  it  to  congestion  or  inflammation,  or  to  a  lesion 
of  the  nerves  of  the  lining  membrane  and  pulp,  or  of  the  peri- 
dental membrane. 

Inflammation  of  the  lining  membrane  and  pulp  may  be  pro- 
duced by  a  blow  upon  a  tooth,  or  by  powerful  impressions  of  heat 
and  cold  communicated  through  the  enamel  and  dentine,  or 
through  a  metallic  filling;  but  it  is  more  frequently  occasioned 
by  pressure,  or  by  the  direct  contact  of  irritating  agents,  such 
as  carious  portions  of  the  tooth,  particles  of  food,  acrid  humors, 
and  other  irritating  external  substances.  But  inflammation  is 
not  always  a  necessary  consequence  of  such  impressions.  Pain 
may  be  produced  by  them  when  inflammation  does  not  exist; 
in  this  case  it  usually  subsides  soon  after  the  removal  of  the 
irritant.  Indeed,  the  pulp  of  a  tooth  may  be  exposed  for 
months,  and  subjected  several  times  every  day  to  the  contact  of 
foreign  substances,  without  becoming  the  seat  of  inflammatory 
action ;  and  in  the  absence  of  this,  the  pain,  though  coming  on 
with  the  suddenness  of  an  electric  flash,  and  often  of  the  most 
excruciating  kind,  is  seldom  of  long  duration. 

But  when  inflammation  exists,  the  pain,  which  at  first  amounts 
only  to  a  slight  gnawing  sensation,  is  more  constant;  after  a 
while,  it  assumes  a  throbbing  character,  and  if  not  promptly 
arrested,  it  increases  in  severity,  and  continues  until  suppuration 
of  the  lining  membrane  and  pulp  takes  place.  So  long  as  it  is 
confined  to  the  parts  within  the  pulp-cavity,  the  pain  is  not 
increased  by  pressure  on  the  tooth ;  nor  is  the  tooth  started  from 
the  socket,  as  in  periodontitis.  The  locality  of  the  inflammation 
may  also  be  distinguished  by  the  fact,  that  cold  water  or  ice 
applied  to  the  tooth  generally  gives  relief.  But  the  inflamma- 
tion rarely  confines  itself  long  to  the  interior  of  the  tooth ;  it 
usually  soon  extends  to  the  periosteum  of  the  root  and  its 
socket,  when  a  somewhat  different  train  of  phenomena  are  de- 
veloped. Suppuration,  however,  having  taken  place,  an  abscess 
soon  forms  at  the  extremity  of  the  root. 

The  severity  of  the  pain  attending  odontitis,  (as  inflammation 


CAUSES   OF   TOOTH-ACHE.  347 

of  the  pulp  is  technically  termed,  from  the  supposition  that 
every  part  of  the  organ  is  involved  in  the  diseased  action,)  is, 
doubtless,  owing  to  the  fact  that  this  exceedingly  sensitive  struc- 
ture, as  its  vessels  become  injected,  is  prevented  from  expanding 
by  the  unyielding  nature  of  the  walls  of  the  cavity  in  which  it  is 
situated.  Its  capillaries  being  thus  distended,  must,  as  a  neces- 
sary consequence,  press  upon  the  nerves  which  are  everywhere 
distributed  through  it,  and  the  excruciatingly  painful  throbbing 
sensation,  by  which  this  variety  of  tooth-ache  is  characterized, 
is  produced  by  the  pulsation  of  these  vessels.  Hence,  increased 
action  of  the  heart  and  arteries,  from  whatever  cause  produced, 
augments  the  pain;  it  is  also  more  severe  at  night,  while  the 
body  is  in  a  recumbent  posture,  than  during  the  day,  because 
this  position  gives  an  increased  fullness  to  the  arteries  of  the 
head.  The  phenomena  attending  the  inflammation,  however,  are 
influenced  very  much  by  the  condition  of  the  tooth  and  the  habit 
of  body  of  the  patient. 

When  the  inflammation  is  acute,  it  extends  to  every  part  of 
the  pulp  and  lining  membrane.  It  also  occurs  more  frequently 
before  than  after  these  tissues  have  become  exposed,  and  gene- 
rally terminates  in  suppuration.  Chronic  inflammation  usually 
arises  from  partial  exposure  of  the  pulp,  and  may  exist  for 
months  without  being  attended  with  pain ;  but  the  pulp,  when 
thus  afiected,  is  more  susceptible  of  injury  by  heat  or  cold,  and 
by  irritating  substances ;  and  the  liability  of  the  tooth  to  ache, 
especially  at  night,  is  greatly  increased. 

Tooth-ache  caused  by  acute  inflammation  of  the  investing 
membrane,  is  characterized  by  pain,  at  first  dull,  afterwards 
acute  and  throbbing,  soreness  and  elongation  of  the  tooth,  red- 
ness and  tumefaction  of  the  gums,  and  sometimes  by  swelling  of 
the  cheek;  indicating  the  formation  of  alveolar  abscess.  In 
this  variety  of  odontalgia,  the  tooth  is  often  so  much  raised  in 
its  socket  as  to  interfere  more  or  less  with  mastication. 

The  pain  attending  the  foregoing  pathological  conditions, 
when  severe  and  protracted,  is  often  accompanied  by  constipa- 
tion, head-ache,  dryness  of  the  skin,  flushed  cheeks,  fullness 
and  increased  rapidity  of  pulse,  and  other  constitutional  symp- 
toms. 

The  nervous  susceptibility  of  the  teeth  is  sometimes  so  much 


848  CAUSES    OF   TOOTH-ACHE. 

increased  by  organic  and  even  functional  disturbances  of  other 
and  often  remote  parts,  that  the  mere  contact  of  the  minute 
nerves  of  the  pulp  and  lining  membrane  against  the  wall  of 
dentine  which  encases  them,  is  attended  with  severe  pain. 
This  variety  of  odontalgia  is  termed  sympathetic,  and  is  sup- 
posed to  be  the  result  of  the  transfer  of  nervous  irritation, 
or  more  properly  of  exalted  sensibility  of  the  dental  nerves, 
arising  from  a  morbid  condition  or  functional  disturbance  of 
some  other  part.  If  this  hypothesis  be  true,  it  is  probable  that 
with  this  heightened  nervous  excitability  there  is  a  slight 
increase  of  vascular  action  in  the  pulp,  with  a  corresponding 
increase  of  size  in  its  capillaries;  in  consequence  of  which,  it  is 
fair  to  presume,  the  nervous  filaments  supplying  these  tissues 
would  be  apt  to  respond  painfully  to  the  undue  pressure. 
Though  pain,  arising  from  this  cause,  may  haA^e  its  seat  in  sound 
as  well  as  in  decayed  teeth,  it  occurs  more  frequently  in  the 
latter  than  the  former,  owing  to  the  fact  that  any  structural 
alteration  in  the  dentine  adds  to  their  already  increased  nervous 
excitability. 

Persons  of  highly  excitable  nervous  temperaments,  pregnant 
females,  and  individuals  laboring  under  derangement  of  the 
digestive  organs  are  particularly  subject  to  this  variety  of  tooth- 
ache. Odontalgia  arising  from  pathological  conditions  or  func- 
tional disturbances  of  other  parts,  assumes  a  great  variety  of 
forms.  The  pain  may  be  continued,  but  more  frequently  it  is 
periodical;  it  may  be  confined  to  a  single  tooth,  or  it  may  attack 
half  a  dozen  or  more  at  the  same  time.  It  sometimes  also  alter- 
nates with  the  paroxysms  of  rheumatism  or  gout,  the  pain  in 
such  cases  assuming  the  specific  character  of  these  diseases. 

Mr.  W.,  aged  40,  for  fifteen  years  the  victim  of  gout,  came  to 
me  in  1830.  The  first  right  upper  molar  was  carious,  but  the 
pulp  not  exposed.  Ten  or  twelve  days  before  each  attack  of 
gout,  recurring  every  three  or  six  months  during  the  last  five 
years,  this  tooth  was  the  seat  of  a  peculiar  grinding,  lancinating 
pain;  becoming  gradually  more  severe,  but  ceasing  entirely  as 
the  gout  symptoms  came  on,  it  returned  as  these  subsided,  and 
continued  for  two  weeks.  Filling  the  tooth  gave  temporary 
relief  only,  and  it  was  found  necessary  to  extract  it. 

In  what  is  termed  neuralgic  tooth-ache,  "the  pain,"  says  Dr. 


CAUSES  OF  TOOTH  ACHE.  349 

Wood,  "  is  usually  of  the  acute  character;  sometimes  mild  in  the 
beginning,  gradually  increasing  in  intensity,  and  as  gradually 
declining,  but  usually  very  irregular ;  at  one  time  moderate,  at 
another  severe,  and  occasionally  darting  with  excruciating  vio- 
lence through  the  dental  arches.  Not  unfrequently  it  assumes 
a  regular  intermittent  form.  Instead  of  pain,  strictly  speaking, 
the  sensation  is  sometimes  of  that  kind  which  is  indicated  when 
we  say  that  the  teeth  are  on  edge,  and  is  apt  to  be  excited  by 
certain  harsh  sounds,  such  as  that  produced  in  the  filing  of  a  saw 
or  by  mental  inquietude,  and  by  the  contact  of  acids  or  other 
irritant  substances.  Neuralgic  tooth-ache  sometimes  persists, 
with  intervals  of  exemption,  for  a  great  length  of  time.  The 
diagnosis  is  occasionally  difiicult.  When,  however,  it  occurs  in 
sound  teeth,  is  paroxysmal  in  its  character,  is  attended  with 
little  or  no  swelling  of  the  external  parts,  occupies  a  considerable 
portion  of  the  jaw ;  and  especially  when  it  alternates  or  is  asso- 
ciated with  pain  of  the  same  character  in  other  parts  of  the  face, 
there  can  be  little  doubt  as  to  its  real  nature."  This  variety  of 
sympathetic  tooth-ache  is  perhaps  induced  by  caries,  or  by  the 
manner  in  which  the  teeth  are  arranged  in  the  alveolar  arch,  or 
by  some  peculiar  susceptibility  of  the  parts ;  as  is  shown  by  the 
fact,  that  the  pain  usually  ceases  on  the  removal  of  all  such  causes 
of  irritation. 

But  while,  on  the  one  hand,  pain  in  the  teeth  may  be  caused 
by  a  morbid  condition  of  other  organs,  these  organs,  on  the 
other  hand,  frequently  sympathize  with  the  diseased  condition  of 
the  teeth,  and  become,  to  quote  the  language  of  Mr.  Bell,  "  the 
apparent  seat  of  pain.  I  have  seen  this  occur  not  only  in  the 
face,  over  the  scalp,  in  the  ear,  and  underneath  the  lower  jaw; 
but  down  the  neck,  over  the  shoulder,  and  along  the  whole 
length  of  the  arm."  Cases  of  this  sort  are  frequently  met 
with. 

In  treating  of  tooth-ache.  Dr.  Good  observes:  "This  is  often 
an  idiopathic  affection,  dependent  upon  a  peculiar  irritability 
(from  a  cause  we  cannot  easily  trace)  of  the  nerves  subservient 
to  the  aching  tooth,  or  of  the  tunics  by  which  it  is  covered,  or 
of  the  periosteum,  or  the  fine  membrane  that  lines  the  interior 
of  the  alveoli.  But  it  is  more  frequently  a  disease  of  sympa- 
thy, produced  by  pregnancy,  or  chronic  rheumatism,  or  acrimony 


350  TREATMENT    OF   TOOTH-ACHE. 

in  the  stomach,  in  persons  of  an  irritable  habit.  It  is  still  less 
to  be  wondered  at,  that  the  nerves  of  the  teeth  should  often  asso- 
ciate in  the  maddening  pain  of  facial  neuralgia,  or  tic  doulour- 
eux, as  the  French  writers  sometimes  term  it;  for  here  the  con- 
nection is  both  direct  and  immediate.  In  consequence  of  this, 
the  patient,  in  most  instances,  regards  the  teeth  themselves  as  the 
salient  points  of  pain,  (as  they  unquestionably  may  be  in  some 
cases,)  and  rests  his  only  hope  of  relief  upon  extraction ;  but 
when  he  applies  to  the  operator,  he  is  at  a  loss  to  fix  upon  any 
particular  tooth.  Mr.  Fox  gives  a  striking  example  of  this,  in  a 
person  from  whom  he  extracted  a  stump  which  afforded  little  or 
no  relief;  in  consequence  of  which  his  patient  applied  to  him 
only  two  days  afterward  and  requested  the  removal  of  several 
adjoining  teeth,  which  were  perfectly  sound.  This  he  objected 
to,  and  suspecting  the  real  nature  of  the  disease,  he  immediately 
took  him  to  Sir  Astley  Cooper,  who,  by  dividing  the  affected 
nerve,  produced  a  radical  cure  in  a  few  days."  The  author  is 
acquainted  with  a  gentleman  similarly  affected.  He  has  had  all 
his  teeth  on  the  right  side  of  both  jaws  extracted,  without  ob- 
taining any  relief. 

There  is  still  another  cause  of  tooth-ache,  which  we  should 
not  omit  to  mention — exostosis;  but  from  the  obscurity  of  the 
diagnosis,  the  existence  of  the  affection  can  seldom  be  deter- 
mined with  positive  certainty,  except  by  the  removal  of  the 
tooth.  As  we  shall  hereafter  have  occasion  to  treat  of  this  dis- 
ease, it  is  unnecessary  in  this  place  to  dwell  upon  the  subject. 

Finally,  some  teeth,  from  peculiar  constitutional  idiosyncrasy, 
are  more  liable  to  odontalgia  than  others.  It  sometimes  happens 
that  every  tooth  in  the  mouth  is  destroyed  by  caries  without  be- 
ing affected  with  pain,  while  at  other  times,  teeth  apparently 
sound  become  the  seat  of  the  most  agonizing  torture. 

TREATMENT. 

The  first  thing  to  be  attended  to  in  the  treatment  of  tooth- 
ache is  the  removal  of  the  causes  which  have  given  rise  to  it ; 
this  can  only  be  done  by  carrying  out  the  curative  and  remedial 
indications  of  the  morbid  conditions  and  functional  disturbances 
with  which  it  is  connected.     While  these  continue,  it  will  be  im- 


TREATMENT    OF    TOOTH-ACHE.  351 

possible  to  obtain  permanent  relief.  The  sensibility  of  the 
nerves  supplying  a  tooth  may  often  be  obtunded,  and  the  pain 
palliated  by  the  application  of  stimulating  and  anodyne  agents 
to  the  exposed  pulp ;  but  the  relief  thus  procured  is  seldom  of 
long  duration.  When  their  effects  subside,  the  pain  usually  re- 
turns with  increased  severity.  When  the  pain  arises  from  chronic 
inflammation  and  irritation,  produced  by  external  agents  on  an 
exposed  portion  of  the  lining  membrane,  such  applications  may 
often  be  employed  with  great  advantage ;  and  among  those  which 
have  been  used  for  this  purpose  are  creosote,  the  oil  of  cloves, 
cinnamon,  etc. ;  laudanum,  spirits  of  camphor,  tannin,  ether  and 
chloroform.  But  of  all  the  remedies  prescribed  by  the  author, 
he  has  found  none  more  useful  in  allaying  the  pain  than  the 
following : 


Sulphuric  aether, 

!i- 

Sulphuric  sether, 

!i- 

Powdered  camph., 

3ij- 

Creosote, 

5ss. 

Powdered  alum, 

3ij- 

Ext.  of  nut-galls, 

3i- 

Sulphate  of  morphia, 

grs.  ij. 

Powdered  camph. 

5ss 

The  alum  should  be  very  finely  powdered,  and  all  the  ingredients  well  mixed 
before  use. 

After  removing  all  foreign  matter  and  carefully  drying  the 
cavity  of  the  tooth,  a  small  bit  of  cotton  or  lint  dipped  in  either 
of  the  above  mixtures  may  be  applied,  and  renewed  several  times 
a  day  if  necessary.  The  relief  obtained  is,  in  the  majority  of 
cases,  almost  instantaneous ;  but  as  the  effect  is  only  temporary, 
the  pain  is  apt  to  recur.  The  author  has  sometimes  used  a  thick 
solution  of  gutta-percha  in  chloroform.  The  application  of  a 
drop  or  two  of  this  to  the  exposed  pulp  is  usually  followed  by 
the  immediate  cessation  of  pain,  and  as  the  chloroform  evapo- 
rates, a  thin  layer  of  gutta-percha  remains  and  serves  for  a  time 
as  a  sort  of  protection  to  the  pulp. 

But  the  only  way  in  which  permanent  exemption  from  pain 
can  be  procured  is,  by  the  extraction  of  the  tooth  or  the  destruc- 
tion of  the  pulp;  it  often  becomes  necessary  to  have  recourse  to 
the  latter,  as  there  are  many  cases  in  which  the  patient  cannot 
be  prevailed  upon  to  submit  to  the  former,  and  as  there  are 
others  in  which  the  retention  of  the  organ  is  called  for  by  some 
peculiar  necessity.  This  may  be  effected  either  by  immediate 
extirpation  with  a  small  sharp-pointed  elastic  stilet  or  probe,  by 


352  TREATMENT    OF    TOOTH-ACHE. 

the  actual  cautery,  arsenious  acid,*  cobalt,  or  chloride  of  zinc. 
Immediate  extirpation,  arsenic,  or  cobalt  are  the  means  usually 
employed  for  the  purpose;  but  we  have  already  described  the 
manner  in  which  the  destruction  of  the  pulp  is  effected  by  each 
of  these. 

Pain  in  a  tooth  arising  from  acute  inflammation  of  the  pulp 
and  lining  membrane,  can  only  be  relieved  by  the  extraction  of 
the  tooth,  the  destruction  of  the  pulp,  or  by  subduing  the  in- 
flammatory action ;  the  last  can  seldom  be  done  except  by  the 
most  energetic  treatment  in  the  very  beginning  in  cases  where 
the  decay  has  not  penetrated  to  the  pulp-cavity.  The  propriety 
or  impropriety  of  extraction  will  be  determined  by  the  amount 
of  pain,  the  progress  made  by  the  inflammation,  the  condition 
of  the  parts  with  which  the  tooth  is  immediately  connected,  the 
effect  of  the  local  distui'bance  upon  the  general  system,  the  situ- 
ation and  importance  of  the  tooth,  and  the  extent  of  structural 
alteration  which  has  taken  place  in  the  crown.  If  the  retention 
of  the  tooth,  on  account  of  its  location,  or  the  loss  of  several 
other  teeth,  is  of  great  importance  to  the  patient;  and  the  cir- 
cumstances of  the  case  justify  a  well-grounded  belief  that  it  can 
be  preserved  and  rendered  useful,  without  acting  as  a  morbid 
irritant,  the  operation,  if  possible,  should  be  avoided.  In  this 
case,  supposing  the  inflammation  to  have  proceeded  too  far  to  be 
arrested,  the  pulp  may  be  destroyed  and  the  tooth  treated  in  the 
manner  described  in  another  chapter;  as  it  would  be  useless  to 
prolong  the  suffering  of  the  patient  by  attempting  any  other 
treatment  in  the  vain  hope  of  securing  the  permanent  preserva- 
tion of  the  organ.  Indeed,  after  the  lining  membrane  has  be- 
come exposed,  removal  of  the  pulp  is  the  only  method  which,  in 
any  stage  of  the  inflammation,  holds  out  a  fair  prospect  qf 
success. 

When  the  inflammation  is  produced  by  other  causes  than  ex- 
posure of  the  pulp  and  the  contact  of  external  irritants,  it  may, 
perhaps,  be  successfully  combated.  The  treatment  is  similar  to 
that  for  local  inflammation  in  other  parts  of  the  body;   the 

*  The  employment  of  arsenious  acid  for  the  destruction  of  an  exposed  dental  pulp, 
and  the  relief  of  the  pain  arising  therefrom,  originated  with  the  late  Dr.  Spooner,  of 
Montreal,  and  in  1835  it  was  recommended  to  the  profession  by  his  brother,  Dr.  S. 
Spooner,  of  New  York,  in  an  excellent  popular  treatise  upon  the  teeth. 


TREATMENT    OF    TOOTH-ACHE.  353 

administration  of  saline  cathartics,  the  application  of  leeches  to 
the  gum  of  the  affected  tooth,  abstinence  from  animal  food  and 
from  stimulating  drinks.  If  the  pulse  is  full  and  hard,  blood 
may  be  taken  from  the  arm  with  advantage.  Should  these 
means  fail  to  arrest  the  inflammation,  and  suppuration  take 
place,  the  formation  of  alveolar  abscess  may  be  prevented  by 
promptly  perforating  the  crown  of  the  tooth  for  the  escape  of 
the  matter ;  but  such  cases  usually  terminate  in  periodontitis, 
which,  perhaps,  arise  as  frequently  from  this  as  from  any  other 
cause. 

The  treatment  of  periodontitis  or  inflammation  of  the  invest- 
ing membrane  is,  for  the  most  part,  the  same  as  above ;  in  addi- 
tion to  which,  the  mouth  may  be  gargled  several  times  a  day, 
with  some  cooling  astringent  wash.  Fomentations  to  the  face, 
and  plasters  of  the  seeds  of  hyoscyamus,  mustard,  capsicum, 
with  various  other  narcotic  or  rubefacient  applications  have  some- 
times been  found  useful.  But  when  the  formation  of  alveolar 
abscess  is  threatened,  the  removal  of  the  tooth,  in  most  cases, 
will  be  found  necessary.  If  it  be  an  incisor  or  cuspid,  how- 
ever, the  operation  should  be  performed  as  a  last  resort. 

When  the  inflammation  is  chronic,  the  necessity  for  the  re- 
moval of  the  tooth  is  still  more  urgent.  But  some  eminent 
practitioners  give  us  accounts  of  the  successful  treatment  of 
chronic  abscess  in  teeth  which  have  been  filled  to  the  ex- 
tremity of  the  fang.  Through  the  fistulous  opening  of  the  ab- 
scess, or  through  an  artificial  opening  in  the  alveolus  opposite 
the  end  of  the  fang,  nitrate  of  silver  is  introduced ;  it  is  used 
either  in  strong  solution  or  a  minute  quantity  of  the  solid  nitrate 
is  applied.  Its  application  should  be  continued  at  intervals  of 
several  days  until  the  chronic  diseased  action  is  overruled. 

Tooth-ache  assuming  a  rheumatic  or  gouty  character  calls  for 
a  somewhat  different  plan  of  treatment.  In  addition  to  the 
local  means  already  described,  it  may  be  necessary  to  adopt  the 
constitutional  treatment  applicable  to  rheumatism  and  gout. 
When  the  pain  arises  from  increased  vascular  action  and  nervous 
irritation  of  the  pulp,  occasioned  by  a  disordered  condition  of 
the  digestive  organs,  and  assumes  an  intermittent  form,  an  emetic 
or  cathartic,  followed  by  the  use  of  quinine,  will  generally  afford 
relief,  provided  caries  has  not  penetrated  to  the  pulp-cavity.     If 


354 


TREATMENT    OF    TOOTH-ACHE. 


dependent  on  general  nervous  irritability  of  the  system,  tonics, 
exercise,  change  of  air,  or  such  other  constitutional  measures  as 
the  peculiarities  of  the  case  may  indicate,  should  be  recom- 
mended. 

The  extraction  of  the  tooth  is  the  only  remedy  that  can  be 
relied  upon  for  relief  of  pain  arising  from  exostosis  of  the  root. 
Dr.  Good,  however,  thinks  it  may  be  cured  in  the  early  stages 
by  the  use  of  leeches  and  mercurial  ointment. 


CHAPTER    TENTH. 
EXTRACTION  OF  TEETH. 

There  are  few  operations  in  surgery  that  excite  stronger 
feelings  of  dread,  and  to  which  most  persons  submit  with  more 
reluctance,  than  the  extraction  of  a  tooth.  Many  endure  the 
tortures  of  tooth-ache  for  weeks  and  even  months  rather  than 
undergo  the  operation ;  and,  indeed,  when  we  take  into  consid- 
eration the  frequent  accidents  occurring  in  its  performance  by 
awkward  and  unskillful  individuals,  it  is  not  surprising  that  it 
should  be  approached  with  apprehension.  But  when  performed 
by  a  skillful  hand  and  with  a  suitable  instrument,  the  operation 
is  always  safe,  and  in  a  large  majority  of  the  cases  may  be 
effected  with  ease. 

Dr.  Fitch  relates  a  case  which  will  serve  to  illustrate  the  above 
remarks.  The  subject,  a  resident  of  Botetourt  county,  Va., 
in  having  the  second  right  superior  molar  extracted  by  a  black- 
smith, had  a  large  portion  of  the  jaw  and  five  other  teeth  re- 
moved at  the  same  time.  "The  fangs  of  his  tooth,"  says  Dr. 
Fitch,  "  were  greatly  bifurcated  and  dove-tailed  into  the  jaw, 
and  would  not  pass  perpendicularly  out,  though  a  slight  lateral 
motion  Avould  have  moved  them  instantly.  The  jaw  proved  too 
weak  to  support  the  monstrous  pull  upon  it,  and  gave  way  be- 
tween the  second  and  first  molars,  and  with  it  came  both  the 
anterior  and  posterior  plates  of  the  antrum.  The  broken  portion 
extended  to  the  spongy  bones  of  the  nose,  and  terminated  at  the 
lower  edge  of  the  socket  of  the  left  front  incisor,  containing  six 
sound  teeth,  namely,  the  first  molar,  the  bicuspids,  cuspid,  and 
incisors  of  the  right  side — six  in  all.  The  soft  parts  were  cut 
away  with  a  knife.  A  severe  hemorrhage  ensued,  but  the  patient 
soon  recovered,  though  with  excessive  deformity  of  his  face  and 
mouth." 

Dr.  Cross,  of  North  Carolina,  related  to  the  author  in  1838  a 
case  very  similar  to  the  one  just  quoted.     The  operator  in  this. 


356  EXTRACTION    OF   TEETH. 

as  in  the  other  instance,  was  a  blacksmith ;  in  attempting  to  ex- 
tract one  of  the  superior  molar  teeth  he  brought  away  a  piece  of 
the  jaw  containing  five  other  teeth,  together  with  the  floor  of  the 
antrum  and  its  posterior  and  anterior  walls. 

We  have  adverted  to  these  cases  to  show  the  impropriety  and 
danger  of  entrusting  the  operation  to  individuals  possessing 
neither  knowledge  of  its  principles  nor  skill  in  its  performance. 
Injuries  occasioned  by  the  operations  of  such  persons  have  fre- 
quently come  under  the  immediate  observation  of  the  author,  with 
whom  it  has  always  been  a  matter  of  surprise  that  an  operation 
to  which  such  universal  repugnance  is  felt,  should  ever  be  con- 
fided to  them. 

The  removal  of  a  wrong  tooth,  or  of  two  or  three  instead  of 
one,  are  such  common  occurrences,  that  it  were  well  if  the  pre- 
cautions given  by  the  illustrious  Ambrose  Par^  were  more  gener- 
ally observed.  So  fearful  was  he  of  injuring  the  adjacent  teeth, 
that  he  always  isolated  the  tooth  to  be  extracted  with  a  file  be- 
fore he  attempted  its  removal.  He  regarded  it  as  of  the  greatest 
importance  that  a  person  who  extracted  teeth  should  be  expert 
in  the  use  of  his  "  tooth  mullets ;  for  unless  he  knows  readily 
and  cunningly  how  to  use  them^  he  can  scarcely  so  carry  him- 
self, but  that  he  will  not  force  out  three  teeth  at  once."  Although 
great  improvements  have  been  made  since  his  time  in  the  con- 
struction of  extracting  instruments,  yet  even  now  the  accidents 
to  which  he  alludes  are  of  almost  daily  occurrence. 

It  is  surprising  that  an  operation  so  frequently  called  for 
should  receive  so  little  attention  from  medical  practitioners,  by 
whom,  though  not  strictly  belonging  to  their  province,  it  must 
frequently  be  performed.  This  neglect  can  only  be  accounted 
for,  by  the  too  general  prevalence  of  the  idea,  that  little  or  no 
surgical  skill  is  necessary  to  its  performance.  But  every  phy- 
sician residing  in  the  country,  or  where  the  services  of  a  skillful 
dentist  cannot  always  be  commanded,  should  provide  himself 
with  the  proper  instruments  and  make  himself  acquainted  with 
the  manner  of  performing  this  operation. 


INDICATIONS    FOR   THE    EXTRACTION    OF   TEETH.  357 


INDICATIONS  FOR   THE   EXTRACTION  OF  TEETH. 

With  regard  to  the  indications  that  determine  the  propriety 
of  extraction,  the  author  does  not  deem  it  necessary  to  say  much 
in  this  place,  as  they  are  fully  pointed  out  in  other  parts  of  the 
work.  It  may  be  well,  however,  to  briefly  mention,  in  this 
connection,  a  few  of  the  circumstances  which  call  for  the  ope- 
ration. 

Beginning  with  the  teeth  of  first-  dentition  ;  it  will  be  sufl^icient 
to  state,  that  when  a  tooth  of  replacement  is  about  to  emerge 
from  the  gums,  or  has  actually  made  its  appearance,  either  be- 
fore or  behind  the  corresponding  milk  tooth,  the  latter  should  at 
once  be  removed ;  and  when  the  aperture  formed  by  the  loss  of 
this  is  so  narrow  as  to  prevent  the  former  from  acquiring  its 
proper  position,  it  may  sometimes  be  necessary  to  extract  an 
adjoining  temporary  tooth.  For  more  explicit  directions  upon 
this  subject,  the  reader  is  referred  to  the  chapter  on  the  manage- 
ment of  second  dentition.  Alveolar  abscess,  necrosis  of  the 
walls  of  the  alveolus,  and  pain  in  a  temporary  tooth,  which  can- 
not be  cured  by  any  of  the  usual  remedies,  may  be  regarded  as 
indications  which  call  for  the  operation. 

The  principal  conditions  Avhich  should  determine  the  extrac- 
tion of  a  permanent  tooth,  may  be  enumerated  in  the  following 
order :  First ;  when  a  molar,  from  the  loss  of  its  antagonizing 
tooth,  or  from  other  causes,  has  become  partially  displaced,  or 
is  a  source  of  constant  irritation  to  the  surrounding  parts. 

Second;  a  constant  discharge  of  fetid  matter  from  the  nerve- 
cavity,  through  a  carious  opening  in  the  crown.  There  may, 
however,  be  circumstances  which  would  justify  a  practitioner,  in 
permitting  or  even  advising  the  retention  of  such  a  tooth  ;  as,  for 
example,  when  the  discharge  of  fetid  matter  is  not  very  consider- 
able ;  also,  where  the  tooth  is  situated  in  the  anterior  part  of  the 
mouth,  and  cannot  be  securely  replaced  with  an  artificial  substi- 
tute. The  secretion  of  fetid  matter  may,  in  a  few  cases,  by 
judicious  treatment  be  arrested,  the  tooth  preserved  for  many 
years  by  plugging ;  and  so  the  morbid  influence  it  would  other- 
wise exert  upon  the  surrounding  parts,  may  be  counteracted. 
But  it  is  only  in  the  fewest  number  of  cases,  under  such  circum- 


3.08  INDICATION?    FOR    THE    EXTRACTION    OF   TEETH. 

Stances,  that  so  favorable  a  result  can  be  secured.  A  front  tooth 
should  not  be  sacrificed  unless  called  for  by  some  very  urgent 
necessity;  neither  i^liould  an  upper  incisor  nor  cuspid  be  permit- 
ted to  remain  in  the  mouth,  if  it  exerts  a  manifestly  morbid  ac- 
tion upon  the  surrounding  parts  :  for  in  this  case  the  consequences 
resulting  from  its  retention  in  the  mouth  may  be  worse  than  the 
loss  of  the  tooth. 

Third  ;  a  tooth  which  is  the  cause  of  alveolar  abscess,  should 
not,  as  a  general  rule,  be  permitted  to  remain  :  but,  if  it  be  an 
incisor  or  cuspid,  and  the  discharge  of  matter  through  the  gum 
is  small,  occurring  only  at  long  intervals,  and,  especially,  if  the 
organ  cannot  be  securely  replaced  with  an  artificial  substitute, 
it  may  be  permitted  to  remain.  But  an  incurable  abscess  in  the 
socket  of  a  bicuspid  or  molar,  should  be  considered  as  a  sufficient 
indication  for  the  removal  of  the  tooth. 

Fourth  ;  irregularity  in  the  arrangement  of  the  teeth,  arising 
from  disproportion  between  the  size  of  the  teeth  and  the  size  of 
the  alveolar  arch,  usually  requires  for  its  correction  the  extrac- 
tion of  some  one  or  more  teeth.  But  with  regard  to  the  teeth 
most  proper  to  be  removed,  the  reader  is  referred  to  the  chapter 
on  irregularity;  where  he  will  find  full  directions  for  the  manage- 
ment of  such  cases. 

Fifth  :  all  dead  teeth  and  roots  of  teeth,  and  teeth  which  have 
become  so  much  loosened  from  the  destruction  of  their  sockets 
as  to  be  a  constant  source  of  disease  to  the  adjacent  parts ;  or 
teeth  otherwise  diseased,  that  are  a  cause  of  neuralgia  of  the 
face,  disease  of  the  maxillary  sinus,  dyspepsia,  or  any  other  local 
or  constitutional  disturbance  ;  such  teeth  should,  as  a  general 
rule,  be  extracted. 

There  are  other  indications  which  call  for  the  extraction  of 
teeth,  but  the  foregoing  are  among  the  most  common ;  they  will 
be  found  sufficient,  in  most  instances,  to  determine  the  propriety 
or  impropriety  of  the  operation.  Cases  are  however  continually 
presenting  themselves,  to  which  no  fixed  rules  would  be  found 
applicable,  and  where  an  experienced  judgment  alone  can  deter- 
mine the  practice  proper  to  be  pursued. 

In  conclusion,  it  is  scarcely  necessary  to  say,  that  whenever 
a  tooth  can  be  restored  to  health,  it  should  always  be  done;  but 
tampering  with  such  as  cannot  be  rendered  healthy  and  useful, 


KEY   INSTRUMENT. 


359 


and  which,  by  remaining  in  the  mouth,  exert  a  deleterious  influ- 
ence, not  only  upon  the  adjacent  parts,  but  also  upon  the 
general  health,  cannot  be  too  strongly  deprecated. 


INSTRUMENTS  EMPLOYED  IN  THE  OPERATION. 

Difi"erent  operators  employ  different  instruments.  For  about 
fifty  years,  the  key  of  Garengeot  was  almost  the  only  instrument 
used  in  the  performance  of  the  operation  ;  but  this  has  in  a  great 
measure  been  superseded  by  forceps,  which,  when  properly  con- 
structed, are  far  preferable  ;  yet  as  the  key  is  still  used  by 
some,  and  is  doubtless  in  certain  cases  a  valuable  instrument,  a 
brief  description  of  it  is  here  given. 


KEY  INSTRUMENT. 

"  The  common  tooth-key,"  says  Dr.  Arnot,  "  may  be  regarded 
in  the  light  of  a  wheel  and  axle  ;  the  hand  of  the  operator  acting 
on  two  spokes  of  the  wheel  to  move  it,  while  the  tooth  is  fixed  to 
the  axle  by  the  claw,  and  is  drawn  out  as  the  axle  turns.  The 
gum  and  alveolar  process  of  the  jaw  form  the  support  on  which 
the  axle  rolls." 

Different  dentists  have  their  keys  differently  constructed,  but 
the  principle  upon  which  they  all  act  is  precisely  the  same. 
Some  prefer  the  bent  shaft,  (Fig.  138)  others  the  straight.  Some 

Fig.  138. 


give  a  decided  preference  to  the  round  fulcrum,  others  to  the 
flat ;  and  though  the  success  of  the  operator  depends  greatly  upon 
the  perfection  of  the  instrument,  yet  he  may  remove  a  tooth 


360  KEY    INSTRUMENT. 

more  expertly  by  means  of  a  key  with  which  he  is  familiar,  than 
one  to  which  he  is  unaccustomed,  though  its  construction  be  even 
better.  Fig.  138  represents  a  key  with  bent  shaft  and  two 
hooks,  one  for  molars  and  the  other  for  bicuspids. 

The  author  has  tried  almost  every  variety  of  key  instrument 
that  has  been  used  in  this  country,  and  thinks  the  straight  shank 
with  a  small  round  fulcrum  slightly  flattened  on  each  side,  de- 
cidedly preferable  to  any  other.  The  objection  raised  by  some 
to  the  use  of  such  a  key,  that  it  is  liable  to  interfere  with 
the  front  teeth,  is  without  good  foundation.  It  can  be  used  with 
as  much  safety  as  a  key  of  any  construction,  and  in  most  cases 
can  be  as  easily  applied.  The  round  is  certainly  preferable  to 
the  flat  fulcrum,  because  it  is  less  liable  to  injure  the  gums  and 
the  alveolus.  In  size  it  should  be  a  little  larger  than  a  half-ounce 
bullet. 

Every  key  instrument  should  be  supplied  with  several  hooks, 
diff"ering  in  size,  to  suit  the  teeth  upon  which  they  are  to  be 
applied.  The  hook  described  by  Dr.  Maynard,*  is  preferable  to 
any  which  the  author  has  seen.  It  very  nearly  resembles  the 
eagle's  claw,  except  that  its  curvature  is  rather  greater.  The 
edge  of  the  hook  is  about  the  sixteenth  of  an  inch  in  width,  and 
divided  into  two  points,  by  a  shallow  notch.  A  hook  of  this  de- 
scription is  less  liable  to  slip,  and  can  be  more  readily  applied 
to  a  tooth  than  those  ordinarily  used. 

With  regard  to  the  merits  of  the  key  instrument,  or  of  any  other 
instrument  having  the  same  principle  of  action,  as  compared 
with  the  forceps  presently  to  be  described,  the  author  does  not 
entertain  a  very  high  opinion.  The  following  remarks  quoted 
from  the  late  work  of  M.  Desirabode,  accord  with  the  views 
which  he  has  held  and  promulgated  for  many  years :  "  One  of 
the  most  common  causes  of  fracture  of  the  alveoli  is  a  badly  per- 
formed operation  in  the  mouth ;  although  not  a  very  flattering 
acknowledgment  for  our  art,  it  is  necessary  to  say  it.  If  it  be 
necessary  to  specify  causes,  we  would  not  hesitate  to  name,  in 
the  first  place,  the  use  of  the  key  of  Garengeot ;  for  we  shall 
prove,  in  treating  of  the  extraction  of  teeth,  that  this  dangerous 
implement,  which  is  only  fit  to  mask  the  unskillfulness  of  the 
operator,  is  one  of  the  most  defective  of  surgical  instruments ; 

*  See  Am.  Jour.  Dent.  Sci.  No.  3,  rol.  3. 


MANNER    OF    USING    THE    KEl'    INSTRUMENT.  361 

and  no  practitioner  of  good  sense,  being  convinced  of  its  mode 
of  action,  would  attempt  to  use  it  even  to  extract  a  nail  from  a 
board,  if  he  did  not  desire  to  break  the  surrounding  material." 
Perhaps  this  condemnation  is  too  sweeping.  The  principle  of 
action  of  the  key  is  in  fact  not  unlike  that  of  a  nail-drawer,  or 
tack-puller,  and  is  well  adapted  to  a  certain  class  of  cases: 
namely,  where  one  wall,  either  the  inner  or  outer,  is  decayed 
below  the  alveolus,  while  the  opposite  one  is  still  standing.  The 
fulcrum,  with  a  folded  napkin  or  other  soft  substance  interposed, 
is  placed  against  the  gum  on  the  side  of  the  tooth  most  decayed, 
and  the  hook  adjusted  to  the  neck  of  the  tooth  on  the  opposite 
side. 

MANNER  OF  USING  THE  KEY  INSTRUMENT. 

The  directions  required  for  the  use  of  the  key  are  few  and 
simple ;  but,  as  cases  frequently  occur  to  which  no  general  rules 
can  be  applied,  much  will  depend  on  the  practical  judgment  and 
surgical  tact  of  the  operator.  The  first  step  to  be  taken  in  the 
operation  is  to  separate  the  gum  from  the  neck  of  the  tooth, 
down  to  the  alveolus  ;  this  should  be  done,  not  on  two  sides  only, 
but  round  the  entire  tooth.  For  this  purpose,  suitable  lancets 
should  be  provided.  A  straight,  narrow-bladed  knife,  pointed 
at  the  end,  and  with  one  cutting  edge,  will  be  found  most  con- 
venient for  performing  the  operation  on  the  approximal  sides ; 
it  may  be  most  effectively  used,  by  passing  the  point  of  the  knife 
between  the  neck  of  the  tooth  and  gum,  down  to  the  alveolus, 
with  its  back  downward,  then  cutting  in  the  direction  of  the 
crown.  In  this  way,  the  connection  of  the  gum  to  the  sides  of 
the  neck  of  the  tooth  may  be  thoroughly  severed.  The  same 
kind  of  knife  or  a  common  gum-lancet,  may  be  used  for  separat- 
ing the  gum  from  the  remaining  sides  of  the  tooth.  If  the  gum 
is  not  well  separated,  there  will  be  danger  of  lacerating  it  in  the 
removal  of  the  tooth. 

After  the  tooth  has  been  thus  prepared,  the  key,  with  the 
proper  hook  attached,  should  be  firmly  fixed  upon  it ;  the  fulcrum, 
on  the  inside,  resting  upon  the  edge  of  the  alveolus,  the  ex- 
tremity of  the  claw  on  the  opposite  side,  pressed  down  upon  the 
neck.  The  handle  of  the  instrument  is  then  grasped  with  the 
24 


362  MANNER    OF    USING    THE    KEY    INSTRUMENT. 

riglit  hand,  and  the  tooth  raised  from  its  socket  by  a  firm,  steady 
rotation  of  the  wrist.  The  claw  should  be  pressed  down  with 
the  fore-finger  or  thumb  of  the  left  hand  of  the  operator,  until, 
by  the  rotation  of  the  instrument,  it  becomes  securely  fixed  upon 
the  tooth.  This  precaution  is  necessary  to  prevent  it  from 
slipping ;  an  accident  that  frequently  happens,  and  one  that  is 
always  more  or  less  embarrassing  to  the  dentist. 

If  the  tooth  is  situated  on  the  left  side  of  the  mouth,  the  posi- 
tion of  the  operator  should  be  at  the  right  side  of  the  patient ; 
but,  if  it  be  on  the  right  side,  he  should  stand  before  him.  For 
the  removal  of  a  tooth,  on  the  left  side  of  the  lower  jaw,  or  the 
right  side  in  the  upper,  the  palm  of  the  hand  should  be  beneath 
the  handle  of  the  instrument ;  in  the  extraction  of  one  on  the 
right  side  of  the  lower  jaw,  or  on  the  left  side  in  the  upper,  it 
should  be  above.  The  manner  of  grasping  the  instrument  is  of 
more  importance  than  many  suppose.  If  improperly  held,  the 
operator  loses,  to  a  great  extent,  his  control  over  it. 

The  directions  here  given,  are,  in  some  respects,  different  from 
those  laid  down  by  other  writers  ;  but,  we  are  convinced,  from 
much  experience,  that  they  will  be  found  more  conducive  to  the 
convenience  of  the  operator  and  the  success  of  the  operation 
than  those  usually  given  for  the  use  of  this  instrument. 

There  is  a  diversity  of  opinion,  as  to  whether  a  tooth  should 
be  removed  inwardly  or  outwardly.  Some  direct  the  fulcrum  of 
the  instrument  to  be  placed  to  the  outside  of  the  tooth,  others  to 
the  inside  ;  while  others,  again,  regard  it  as  of  little  importance 
on  which  side  it  is  placed.  Experience  has  taught  us  that  it 
should,  in  the  majority  of  cases,  be  placed  on  the  inside ;  espe- 
cially of  the  lower  teeth,  as  they  almost  always  incline  towards 
the  interior  of  the  mouth.  Moreover,  the  edge  of  the  alveolus 
is  usually  a  little  higher  on  the  exterior  edge  of  the  jaw  than  on 
the  interior ;  so,  that  the  first  motion  of  the  instrument,  with 
its  fulcrum  on  the  outside,  brings  the  side  of  the  tooth  against 
its  socket ;  thus,  nearly  double  the  amount  of  power  is  required 
to  remove  it ;  while,  at  the  same  time,  the  pain  and  the  chances 
of  injury  to  the  alveolar  processes  are  very  much  increased. 

It  is,  however,  frequently  necessary  to  place  the  bolster  of  the 
key  on  the  outside  of  the  tooth  ;  when,  for  instance,  it  is  decayed 
in  such  a  way  as  not  to  afford  a  suflSciently  firm  support  for  the 


FORCEPS.  363 

claw  of  the  instrument.  But,  whenever  it  is  possible  to  remove 
a  tooth  inwardly,  it  should  be  done.  The  alveolar  walls  of  the 
upper  teeth  are,  generally,  thinner  than  those  of  the  lower,  and 
do  not  afford  so  strong  a  support  to  the  fulcrum  of  the  instru- 
ment. 

FORCEPS. 

Forceps  were  not  very  generally  or  extensively  employed, 
except  for  the  extraction  of  the  front  teeth,  until  about  the  year 
1830,  but  the  improvements  made  in  their  construction  since 
that  period  are  so  great,  that  their  use  has  now,  among  dentists, 
almost  superseded  that  of  the  key. 

The  forceps  formerly  used  were  so  awkwardly  shaped,  and  so 
badly  adapted  to  the  teeth,  that  the  extraction  of  a  large  molar 
with  an  instrument  of  this  description,  was  regarded  as  exceed- 
ingly difficult,  and  even  dangerous ;  even  its  practicability  was 
doubted  by  many  of  the  most  experienced  practitioners,  and 
hence,  the  key  was  almost  the  only  instrument  resorted  to  for 
the  purpose. 

When  we  consider  the  strong  prejudice  that  so  recently  existed 
against  the  use  of  forceps,  it  is  not  at  all  wonderful  that  their 
employment  should  have  been  resorted  to  with  caution.  Nor  is 
it  surprising  that  a  gentleman  of  Mr.  Bell's  intelligence  and 
practical  experience,  should,  so  late  as  the  period  of  the  publica- 
tion of  his  work,  1830,  tell  us  that  the  key  is  the  only  instru- 
ment to  be  relied  upon  for  the  removal  of  teeth  that  are  much 
decayed ;  and  that  those  who  have  heaped  the  most  opprobrium 
upon  it,  are  glad  to  have  a  concealed  recourse  to  its  aid. 

This  may  have  been  true  at  the  time  Mr.  B.  wrote,  but  not 
now.  On  the  contrary,  cases  are  daily  occurring  of  the  extrac- 
tion of  teeth  with  forceps,  upon  which  the  key  had  been  previ- 
ously unsuccessfully  employed.  It  is  generally  supposed  that  a 
greater  amount  of  force  is  necessary  to  remove  a  tooth  with 
forceps  than  with  the  key,  but  this  is  a  mistake.  It  does  not 
ordinarily  require  as  much.  The  leverage  gained  by  the  action 
of  the  key  is  more  than  counterbalanced  by  the  greater  amount 
of  resistance  encountered  in  the  lateral  direction  of  the  force 
exerted  in  the  removal  of  the  tooth  by  that  instrument.  But 
with  forceps,  the  direction  of  the  power  being  in  the  line  of  the 


364  FORCEPS. 

axis  of  the  tooth,  an  amount  sufficient  to  break  up  the  connection 
with  the  socket,  and  to  overcome  the  resistance  of  the  walls  of 
the  alveolus  is  all  that  is  required. 

The  author  has  used  forceps  exclusively  since  1834,  and  he 
does  not  hesitate  to  affirm,  that  any  tooth  can  be  extracted  with 
thom  that  can  be  removed  witli  the  key;  and  that,  too,  in  the 
majority  of  cases,  with  greater  ease  to  the  operator  and  less 
pain  to  the  patient.  He  knows  that  in  this  expression  of  opin- 
ion, he  differs  from  many  of  his  professional  brethren;  and  that 
there  are  many  skillful  and  experienced  practitioners,  who,  while 
preferring  forceps  for  the  extraction  of  most  teeth,  occasionally 
use  the  key.  But  he  is  confident  that,  if  they  would  provide 
themselves  with  forceps  properly  constructed  for  the  extraction 
of  those  teeth  which  they  now  remove  with  the  key,  and  use 
them  for  six  months  to  the  exclusion  of  that  instrument,  they 
would  never  again  return  to  its  employment. 

It  may,  perhaps,  require  a  little  more  practice  to  become 
skilled  in  the  use  of  forceps  than  in  that  of  the  key.  We  would, 
therefore,  advise  those  who  have  been  accustomed  to  the  latter, 
not  to  lay  it  at  once  entirely  aside;  but  to  commence  the  use  of 
forceps  on  teeth  that  are  least  difficult  to  remove,  as,  for  example, 
the  bicuspids,  and  afterward  upon  the  molars. 

In  order  that  forceps  may  be  used  with  ease,  it  is  necessary 
they  should  be  properly  constructed.  Every  operator  should 
possess  several  pairs,  (seven  at  least,)  each  with  a  differently- 
shaped  beak,  adapted  to  the  necks  of  the  teeth  to  which  they 
are  respectively  designed  to  be  applied. 

For  the  extraction  of  molars,  the  forceps  recommended  by 
Mr.  Snell  are  the  best  in  use.  His  improvements,  made  in  the 
shape  of  the  beaks  of  the  upper  and  lower  molar  forceps,  are 
very  Valuable ;  to  which  he  is  entitled  to  much  more  credit  than 
the  profession  generally  have  accorded.  For  the  upper  molars 
two  (Fig.  139)  are  required,  one  for  each  side,  curved  just  below 
the  joint,  so  that  the  beak  shall  form  an  angle  of  twenty  or 
twenty-five  degrees  with  the  handles,  just  enough  to  clear  the 
lower  teeth.  The  inner  blade  is  grooved  to  fit  the  neck  of  the 
palatine  root ;  the  outer  blade  has  two  grooves,  with  a  point  in 
the  centre  to  fit  the  depression  just  below  the  bifurcation  of  the 
two  buccal  roots.     Another  valuable  improvement  of  his  consists 


FORCEPS.  365 

in  having  one  of  the  handles  bent  so  as  to  form  a  hook.  This 
passes  round  the  operator's  little  finger,  to  prevent  the  hand 
from  slipping. 

Fig.   139. 


In  the  drawings  which  Mr.  Snell  has  given  of  his  upper  molar 
forceps,  the  hook  is  on  the  palatine  handle  of  each ;  so  that  in 
the  extraction  of  a  right  upper  molar,  the  upper  side  of  the  in- 
strument must  be  grasped,  and  the  lower  side  in  the  extraction 
of  a  left  upper  molar.  But  the  author  has  found  that  they  can 
be  more  conveniently  employed  by  having  the  handle  so  bent, 
that  when  applied,  the  hook  of  each  is  next  the  operator.  (Fig. 
139.)  The  handles  should  be  wide,  and  large  enough  to  prevent 
them  from  springing  under  the  grasp  of  the  hand,  to  which  they 
should  be  accurately  fitted.  Every  dentist,  therefore,  in  having 
forceps  manufactured,  should  give  special  directions  with  regard 
to  their  shape  and  size.  The  beak  should  be  bent  no  more  than 
is  absolutely  necessary  to  prevent  the  handles  from  coming  in 
contact  with  the  teeth  of  the  lower  jaw;  for  in  proportion  to  the 
degree  of  curvature  will  the  muscular  power  of  the  operator  be 
disadvantageously  exerted. 

Each  blade  of  the  beak  of  the  lower  molar  forceps  has  two 
grooves,  with  a  point  in  the  centre,  so  situated  that  in  grasp- 
ing the  tooth  it  comes  between  the  two  roots  just  at  the  bifurca- 


366  FORCEPS. 

tion.  Mr.  Snell  employs  two  pairs  for  the  extraction  of  the 
lower,  as  well  as  for  the  upper  molars,  in  order,  as  he  says,  to 
have  a  hook  to  turn  round  the  little  finger,  which  he  supposes 
must  be  on  opposite  sides  of  the  instrument.  But  this  is  ren- 
dered unnecessary  by  an  improvement  made  by  the  author  in 
1833;  which  consists  in  having  the  handles  of  the  instrument  so 
bent  that  it  may  be  as  readily  applied  to  one  side  of  the  mouth 
as  the  other,  while  the  operator  occupies  a  position  to  the  right 
and  a  little  behind  the  patient.  By  this  improvement,  the  ne- 
cessity for  two  pairs  is  wholly  superseded;  it  moreover  enables 
hira  to  control  the  head  of  the  patient  with  his  left  arm,  and  the 
lower  jaw  with  his  left  hand,  rendering  the  aid  of  an  assistant 
wholly  unnecessary. 

The  shape,  of  the  instrument,  as  improved  by  the  author,  is 
shown  in  Fig.  140.  It  is  now  used  by  many  hundreds  of  opera- 
tors, who  prefer  it  to  any  other  instrument  they  have  ever  em- 
ployed. When  applied  to  a  tooth,  the  handles  turn  toward  the 
operator,  at  an  angle  of  about  twenty-five  or  thirty  degrees. 
Without  this  curvature  in  the  handles,  the  arm  of  the  operator 
would  often  be  thrown  so  far  from  his  body  as  to  prevent  the 
proper  control  over  the  instrument.  It  is  also  important  that 
the  handles  should  be  wide  and  accurately  fitted  to  the  hand. 

F]i;.    140. 


Fur  the  extraction  of  the  upper  incisors  and  cuspids,  one  pair 
only  is  necessary.  (Fig.  141.)  These  should  be  straight,  with 
grooved  or  crescent-shaped  jaws,  accurately  fitted  to  the  necks 
of  the  teeth.  The  beak  should  also  be  thin,  so  that  they  may 
be  easily  introduced  under  the  ^um,  up  to  the  edo;e  of  the  alve- 
olus.     And.   like   the  superior  ami  inferior  molar  forceps,  the 


FORCEPS. 


367 


handles  should  be  large  enough  to  prevent  them  from  springing 
in  the  hand  of  the  operator,  with  a  hook  formed  at  the  end  of 
one  of  them. 

Fig.  141. 


For  the  extraction  of  the  lower  incisors,  a  pair  of  very  nar- 
row-beaked forceps  are  necessary,  to  prevent  interfering  with 
the  teeth  adjoining  the  one  to  be  removed.  The  beak  below  the 
joint  of  the  instrument  should  be  bent  downward  at  an  angle  of 
about  twenty-five  degrees  with  the  handles.  (Fig.  142.)  This  is 
also  a  very  valuable  instrument  for  the  extraction  of  the  roots 
of  teeth. 

Fig.  142. 


An  instrument  similarly  shaped,  but  with  the  beak  much  longer, 
makes  one  of  the  most  universally  applicable  instruments  that 
can  be  devised.     The    beak   should  be  made  strong,  but  very 

narrow. 

Fig.  143. 


Forceps  for  the  extraction  of  bicuspids  should  have  their  jaws 
so  bent  as  to  be  easily  adapted  to  these  teeth;  they  should  be 


368 


FORCEPS. 


narrow  and  have  a  deeper  groove  on  the  inside  than  those  for 
the  upper  incisors  and  cuspids;  like  them,  they  should  be  thin, 
yet  strong  enough  to  sustain  the  pressure  which  it  may  be  neces- 
sary to  apply.  One  pair  will  answer  for  the  bicuspids  of  both 
jaws,  but  in  this  case  both  handles  must  be  straight.  (Fig.  143.) 
For  the  removal  of  the  cuspids  of  the  low^er  jaw,  the  hawk's- 
bill  forceps,  (Fig.  144)  with  crescent-shaped  beaks,  are  often 
employed ;  but  the  instrument  last  described  is,  we  think,  better 

Fig.   144. 


suited  to  the  extraction  of  these  teeth,  and  can  be  more  conve- 
niently applied.  No  separate  instrument,  therefore,  is  required 
for  the  removal  of  the  inferior  cuspids. 

The  dentes  sapientioe  can,  in  a  large  majority  of  cases,  be  as 
readily  extracted  with  the  bicuspid  forceps  as  with  any  other; 
and  these  can  be  as  conveniently  applied  to  the  teeth  of  the 
upper  as  to  those  of  the  lower  jaw. 

But  there  is  another  kind  of  forceps,  which  may  be  employed 
for  the  removal  of  the  upper  wisdom  teeth,  where  the  bicuspid 

Fh;.  145. 


forceps  cannot  be  used.     The  beak  of  these  is  bent  above  the 
joint,  forming   nearly  two  right-angles,  as    shown   in    Fig.  145. 


FORCEPS.  369 

These  forceps  were,  we  believe,  invented  by  Dr.  Edward  P. 
Church,*  about  the  year  1830,  and  in  those  cases  where  the  su- 
perior dentes  sapientijB  are  considerably  shorter  than  the  second 
molars,  they  can  be  successfully  and  advantageously  employed ; 
and  indeed,  in  many  cases,  they  cannot  be  reached  with  any  of 
the  above-described  extracting  instruments.  These  forceps  are 
also  useful  in  the  extraction  of  roots  of  teeth  situated  behind 
a  bicuspid  or  molar  tooth  which  has  a  very  long  crown.  The 
handles  of  these,  as  of  all  other  forceps,  should  be  no  longer 
than  is  absolutely  necessary  for  the  accommodation  of  the  hand 
of  the  operator. 

A  great  variety  of  forceps  have  been  invented  and  used  for 
the  extraction  of  teeth ;  but  the  author  has  not  seen  any  that  he 
deems  comparable  with  those  which  he  has  just  described.  Seven 
pairs  are  all  that  are  really  necessary ;  and  these,  if  properly 
constructed,  are  better  and  more  efficient  than  thirty  pairs  of  the 
awkwardly-contrived  instruments  which  many  dentists  use. 

In  truth,  there  is  scarcely  any  instrument  used  in  dentistry 
that  has  called  forth  more  ingenuity  in  devising  various  shapes. 
Almost  every  practitioner  has  some  peculiar  pattern  of  his  own 
which  will  accomplish  Avhat  no  other  can.  Doubtless  many  of 
these  instruments  are  very  excellent;  but  it  often  happens  that 
an  inventor  learns,  by  dint  of  practice,  to  do  with  some  pet  for- 
ceps of  his  own  contrivance  what  might  as  easily  have  been  done 
with  a  simpler  one  already  in  use.  We  would  not,  however,  be 
understood  as  saying  that  patterns  in  present  use  admit  of  no 
improvement.  What  we  do  assert  is,  that  skill  in  the  use  of  a 
few  instruments  is  preferable  to  crowding  one's  case  with  an 
unnecessary  number. 

*  Dr.  Church  was  an  ingenious  and  talented  man,  and  during  the  four  years  of  his 
brief  professional  career  he  acquired  a  reimtatiou  for  skill,  which  few,  in  so  short  a 
time,  have  been  able  to  achieve;  had  hi:;  life  been  spared,  he  would  soon  have  ranked 
among  the  very  first  practitioners  in  the  country.  Born  in  the  western  part  of  the 
State  of  New  York,  he  chose  the  Mississii)pi  Valley  as  the  field  of  his  professional 
labors,  intending  ultimately  to  locate  in  Cincinnati:  but  while  on  a  visit  to  his  family, 
in  1832,  he  fell  a  victim  to  the  Asiatic  eholora,  in  the  twenty-sixth  year  of  his  age. 


370  MANNER    OF    USING    THE    FORCEPS. 


MANNER  OF  USING  THE  FORCEPS. 

In  describing  the  manner  of  using  these  instruments,  we  shall 
commence  with  the  extraction  of  the  incisors  of  the  upper  jaw. 
These  are  generally  more  easily  removed  than  any  of  the  other 
teeth. 

The  use  of  the  gum  lancet  should  generally  precede  the  appli- 
cation of  either  the  forceps  or  the  key.  Many  dentists  object 
to  the  operation  as  unnecessarily  inflicting  double  pain.  Some 
have  their  forceps  made  with  thin  sharp  blades  so  as  to  sever  the 
gum  on  two  sides  in  the  act  of  pressing  up  the  instrument.  This 
practice  may  be  admissible,  perhaps  necessary  in  certain  ex- 
ceptional cases ;  as  with  children,  or  nervous  persons,  whom  the 
act  of  lancing  might  deter  from  permitting  the  operation  to  be 
completed.  But  we  are  fully  satisfied  that  as  a  rule  it  is  very 
objectionable,  either  in  the  use  of  the  key  or  of  forceps.  After 
separating  the  gum  from  the  neck  of  the  tooth,  it  should  be 
grasped  with  a  pair  of  straight  forceps  (Fig.  141),  and  pressed 
several  times,  in  quick  succession,  outward  and  inward,  giving  it 
at  the  same  time  a  slight  rotary  motion,  which  should  be  con- 
tinued until  it  begins  to  give  way ;  then,  by  a  slight  downward 
pull,  it  is  easily  removed.  If  the  tooth  is  much  decayed,  it 
should  be  grasped  as  high  up  under  the  gum  as  possible,  and  no 
more  pressure  applied  to  the  handles  of  the  instrument  than 
may  be  necessary  to  prevent  it  from  slipping.  Teeth  are  often 
unnecessarily  broken  by  not  attending  to  this  precaution. 

The  same  directions  will,  in  most  cases,  be  found  applicable 
for  the  removal  of  a  lower  incisor.  But  the  arrangement  of  these 
teeth  is  sometimes  such  as  to  render  their  extraction  rather  more 
difficult.  The  forceps  best  calculated  for  their  removal  are  re- 
presented in  Fig.  142. 

For  the  extraction  of  a  cuspid,  more  force  is  usually  required, 
than  for  the  removal  of  an  incisor,  because  of  the  greater  size 
and  length  of  its  fang.  The  straight  forceps  (see  Fig.  141) 
should  be  employed  for  the  removal  of  the  superior,  and  the 
curved-beaked  forceps  (Fig.  143)  for  the  inferior  cuspids.  In 
the  extraction  of  these  teeth,  less  rotary  motion  should  be  given 
to  the  hand  than  in  the  removal  of  the  incisors :  in  every  other 


MANNER    OF    USING    THE    FORCEPS.  371 

respect,  the  operation  is  performed  in  the  same  manner.  The 
inferior  cuspids  usually  have  longer  roots,  and  are  more  difficult 
to  remove  than  the  superior. 

Very  little  rotary  motion  can  be  given  to  a  bicuspid,  especially 
an  upper  one,  in  its  extraction.  After  it  has  been  pressed  out- 
ward and  inward  several  times,  or  until  it  begins  to  give  way,  it 
should  be  removed  by  pulling  in  the  direct  line  of  its  axis.  For 
the  extraction  of  the  upper,  the  forceps  represented  in  Fig.  141, 
and  for  the  lower,  those  represented  in  Fig.  143,  are  the  proper 
instruments  to  be  employed ;  unless  the  crown  has  become  so 
much  weakened  by  decay,  that  it  will  not  bear  the  requisite 
amount  of  pressure.  In  this  case,  the  gum  on  each  side  should 
be  separated  from  the  alveolus,  about  an  eighth  or  three- 
sixteenths  of  an  inch,  and  slitted  so  as  to  permit  the  application 
of  the  narrow-beaked  forceps.  Fig.  142.  With  these,  the  alveolar 
wall  on  each  side  may  be  easily  cut  through,  and  a  sufficiently 
firm  hold  obtained  upon  the  root  of  the  tooth,  for  its  removal. 
These  forceps  will  also  be  found  better  adapted  for  the  removal 
of  the  molars,  when  in  a  similar  condition,  than  any  other  in- 
strument. 

The  upper  molars,  having  three  roots,  generally  require  a 
greater  amount  of  force  for  their  removal  than  any  of  the  other 
teeth.  They  should  be  grasped  as  high  up  as  possible,  with  one 
of  the  forceps  represented  in  Fig.  139,  and  then  pressed  out- 
ward and  inward,  until  the  tooth  is  well  loosened,  when  it  may 
be  pulled  from  the  socket.  If  the  forceps  used  for  the  extrac- 
tion of  the  upper  molars  are  of  the  right  description  and  pro- 
perly applied,  they  will  be  found  the  safest  and  most  efficient 
instruments  that  can  be  employed  for  their  removal. 

The  superior  dentes  sapientiee  are  usually  less  firmly  articu- 
lated to  the  jaw  than  are  the  first  and  second  molars;  they  are 
therefore  more  easily  removed.  "When  their  crowns  are  suffi- 
ciently long  to  admit  of  being  grasped  with  the  bicuspid  forceps 
(Fig.  143),  they  should  be  removed  with  this  instrument;  but 
when  this  cannot  be  applied  without  interfering  with  the  anterior 
teeth,  the  forceps  represented  in  Fig.  145  may  be  substituted. 

The  inferior  molars,  although  they  have  but  two  roots,  are 
often  very  firmly  articulated,  and  require  considerable  force  for 
their  removal ;  and  it  sometimes  happens  that,  when  the  approxi- 


372  MANNER    OF    USING   THE    FORCEPS. 

mal  side  of  one  has  been  destroyed  by  caries,  the  adjoining  tooth 
has  impinged  upon  it  in  such  a  manner  as  to  constitute  a  for- 
midable obstacle  to  its  extraction.  Two  teeth  are  often  removed 
in  attempting  to  extract  one  thus  situated,  unless  the  precaution 
is  taken  of  filing  off  the  side  of  the  encroaching  tooth.  This 
should  never  be  omitted  in  the  extraction  of  a  lower  molar  or 
bicuspid,  locked  in  the  manner  just  described.  It  sometimes, 
though  less  frequently,  happens  that  the  upper  teeth  impinge 
upon  each  other  in  the  same  manner;  in  this  case,  also,  the 
adjoining  tooth  should  be  filed  sufficiently  to  liberate  the  one 
that  is  to  be  extracted  before  attempting  its  removal.  In  apply- 
ing forceps  to  an  inferior  molar,  the  points  on  the  beak  of  the 
instrument  should  be  forced  down  between  the  roots;  after 
having  obtained  a  firm  hold,  the  tooth  should  be  forced  outward 
and  inward  several  times  in  quick  succession,  until  its  connection 
with  the  jaw  is  partially  broken  up,  and  then  raised  from  the 
socket.  If  the  tooth  has  decayed  down  to  the  neck,  the  points 
of  the  beak  may  include  the  upper  edge  of  the  alveolus,  through 
which  they  will  readily  pass,  on  applying  pressure  to  the  handles, 
and  in  this  manner  a  secure  hold  will  be  obtained  upon  the  tooth. 
The  same  should  also  be  done  in  the  extraction  of  a  superior 
molar  in  this  condition. 

The  dentes  sapientiae  in  the  lower  jaw,  when  situated  far  back 
under  the  coronoid  processes,  are  oftentimes  exceedingly  diflScult 
to  extract ;  but  with  forceps  like  those  represented  in  Fig.  142, 
they  may  always  be  grasped  by  an  expert  operator;  except  in 
those  cases  where  their  crowns  have  been  destroyed  by  caries, 
when  a  portion  of  the  alveolus  should  be  cut  away,  either  with 
forceps,  or  a  strong  sharp-pointed  instrument,  previously  to 
attempting  their  removal.  It  occasionally  happens  that  the 
roots  of  these  teeth  are  bent  in  such  a  manner  as  to  constitute 
a  considerable  obstacle  to  their  removal.  But  when  this  is  the 
case,  the  roots  are  almost  always  turned  posteriorly  toward  the 
coronoid  processes;  so  that  after  starting  the  tooth,  if  the  ope- 
rator is  unable  to  lift  it  perpendicularly  from  the  socket,  he  will 
have  reason  to  suspect  its  retention  to  be  owing  to  an  obstacle 
of  this  nature.  To  overcome  this,  as  he  raises  his  hand,  he 
should  push  the  crown  of  the  tooth  backward,  making  it  describe 
the  segment  of  a  circle ;  for  should  he  persist  in  his  efforts  to 


MANNER    OF    EXTKACTING    ROOTS    OF    TEETH.  373 

remove  it  directly  upward,  the  root  will  be  broken  and  left  in 
the  jaw. 

It  sometimes  happens  that  the  roots  of  the  first  and  second 
molars  of  both  jaws,  and  those  of  the  superior  dentes  sapientise, 
are  bent,  or  else  diverge  or  converge  so  much  as  to  render  their 
extraction  exceedingly  diificult.  The  convergency  of  these  roots 
is  often  so  great  that,  in  their  removal,  the  intervening  wall  of 
the  alveolus  is  brought  away;  but  neither  from  this,  nor  from 
the  removal  of  a  portion  of  the  exterior  wall,  will  any  unplea- 
sant results  follow.  Similar  malformations  are  occasionally  met 
with  in  the  roots  of  the  bicuspids,  the  cuspids,  and  even  the 
incisors. 

Other  obstacles  sometimes  present  themselves  in  the  extraction 
of  teeth,  which  the  judgment  and  tact  of  the  operator  alone  will 
enable  him  to  overcome.  The  nature  and  peculiarity  of  each 
case  will  suggest  the  method  of  procedure  most  proper  to  be 
pursued.  The  dentist  should  never  hesitate  to  embrace  a  portion 
of  the  alveolus  between  the  jaws  of  the  forceps,  when  necessary 
to  enable  him  to  obtain  a  firm  hold  upon  the  tooth.  The  removal 
of  the  upper  edge  of  the  socket  is  never  productive  of  injury, 
as  it  is  always  subsequently  removed,  more  or  less  rapidly,  by 
the  process  of  absorption.  When  the  crown  of  a  tooth  has 
become  so  much  weakened  by  disease  that  it  will  not  bear  the 
pressure  of  the  instrument,  it  may  be  removed  in  this  manner 
without  inflicting  upon  the  patient  half  the  pain  that  would  be 
caused  by  the  attempt  to  spare  the  thin,  perishable  alveolar 
walls. 

MANNER  OF  EXTRACTING  ROOTS  OF  TEETH. 

The  extraction  of  roots  of  teeth  is  sometimes  attended  with 
considerable  difficulty;  but,  generally,  they  are  more  easily 
removed  than  the  whole  teeth,  especially  the  roots  of  the 
molars;  for  after  the  destruction  of  their  crowns,  an  effort  is 
usually  made  by  the  economy  to  expel  them  from  the  jaws. 
This  is  done  by  the  gradual  absorption  of  the  alveolus,  together 
with  the  filling  up  of  the  socket  by  a  deposition  of  ossific  matter 
at  the  bottom;  whereby  the  articulation  of  the  root  becomes 
weakened,  and  its  removal  rendered  proportionably  easier.    The 


374 


MANNER    OF    EXTRACTING    ROOTS    OF   TEETH. 


alveolar  cavities  are  often  wholly  obliterated  in  the  course  of  two 
or  three  years  after  the  destruction  of  the  crowns  of  the  teeth, 
and  the  roots  retained  in  the  mouth,  simply  by  their  connection 
with  the  gums;  so  that  for  their  removal  little  more  is  necessary 
than  to  sever  this  bond  of  union  with  a  lancet  or  sharp-pointed 
knife. 

The  instruments  usually  employed  in  the  extraction  of  roots 
of  teeth,  are  the  hook,  punch,  elevator  and  screw;  all  of  which 
are  represented  in  Figs.  146  and  147.  Although  every  dentist 
has  them  made  to  suit  his  own  peculiar  notions,  the  manner  of 
using  them,  and  the  principle  upon  which  they  act,  are  the  same. 
It  will,  therefore,  be  sufficient  to  say,  that  they  should  be  of  a 
convenient  size,  made  of  good  steel,  and  so  tempered  as  neither 
to  bend  nor  break. 

Fig.  146. 


The  hook  a.  Fig.  146,  is  chiefly  used  for  the  extraction  of  the 
roots  of  molar  and  bicuspid  teeth  on  the  left  side  of  the  mouth  ; 
the  punch  h,  Fig.  146,  for  the  removal  of  those  on  the  right 
side ;  the  elevator  c,  Fig.  147,  for  the  extraction  of  roots  on 
either  side,  a.s  occasion  may  require ;  and  the  screw  d,  Fig.  147, 
for  the  removal  of  those  of  the  upper  front  teeth. 

Considerable  tact  is  necessary  for  the  .skillful  use  of  these  in- 
struments, and  this  can  only  be   obtained   by  practice.     Great 


MANNER    OF    EXTRACTING    ROOTS    OF   TEETH.  375 

care  is  requisite  in  using  the  punch  and  elevator,  to  prevent 
them  from  slipping  and  injuring  the  mouth  of  the  patient. 
Whenever,  therefore,  either  of  these  are  used,  the  forefinger  of 
the  left  hand  of  the  operator  should  he  wrapped  with  a  cotton  or 
linen  rag  and  placed  on  the  side  of  the  root  opposite  to  that 
against  which  the  instrument  is  applied,  so  as  to  catch  the  point 
in  case  it  should  slip. 

But,  for  the  removal  of  the  roots  of  bicuspids  and  molars,  and 
often  for  those  of  the  cuspids  and  incisors,  the  narrow  beaked 
forceps,  recommended  for  the  extraction  of  the  lower  incisors 
(see  Fig.  142),  may  be  used  more  effectively  than  any  other  in- 
strument. When  the  root  is  decayed  down  to  the  alveolus,  the 
gum  should  be  separated  from  it,  and  so  much  of  it  as  may  be 
necessary  to  obtain  a  secure  hold  upon  the  root,  included  between 
the  jaws  of  the  beak  of  the  forceps ;  for  these  being  very  nar- 
row, readily  pass  through  the  alveolus,  and  a  firm  hold  is  at  once 
obtained  upon  the  root;  then,  after  moving  it  a  few  times,  out- 
ward and  inward,  it  may  easily  be  removed  from  its  socket. 
There  are  some  cases,  however,  in  which  the  punch,  hook,  and 
elevator  may  be  advantageously  used.  We  have  also  occasion- 
ally met  with  cases  where  we  have  succeeded  in  removing  roots 
of  teeth  with  great  ease,  by  means  of  an  elevator  shaped  like 
the  blade  of  a  knife,  first  forcing  it  into  the  socket  by  the  side 
of  the  root,  and  then  turning  it  so  as  to  make  the  back  press 
against  the  former,  and  the  edge  against  the  latter.  When  this 
instrument,  represented  in  Fig.  148,  is  used,  the  blade  should 
not  be  more  than  an  inch  in  length,  and  it  should  be  straight, 
short  at  the  point,  and  have  a  very  thick  back,  that  it  may  not 

Fig.  148. 


break  in  the  operation.  In  using  the  common  elevator,  it  is 
necessary  that  there  should  be  an  adjoining  tooth  or  root  to  act 
as  a  fulcrum.  When  this  can  be  employed,  a  root,  or  even  a 
whole  tooth,  may  sometimes  be  removed  with  it ;  but  as  a  general 
rule,  forceps  should  be  preferred  to  any  of  these  instruments. 

For  the  extraction  of  the  roots  of  the  upper  front  teeth,  after 
they  have  become  so  much  funneled  out  by  decay  as  to  render 


376 


MANNER    OF    EXTRACTING    ROOTS    OF   TEETH. 


tlieir  walls  incapable  of  sustaining  the  pressure  of  forceps,  the 
conical  screw  is  invaluable.  With  this  a  sufficiently  firm  hold  for 
the  removal  of  the  root  can  be  obtained  by  screwing  it  into  the 
cavity.  But  before  it  is  introduced  the  soft  decomposed  dentine 
should  be  removed  from  the  interior  of  the  root  with  a  triangular 
pointed  instrument  like  the  one  represented  in  Fig.  149. 

Fig.  149. 


Dr.  S.  P.  Hullihen  has  invented  a  most  valuable  and  useful 
instrument  for  the  removal  of  the  roots  of  the  superior  incisors 
and  cuspids  when  in  the  condition  just  described.  It  combines 
the  advantages  both  of  the  screw  and  forceps,  as  may  be  seen 
by  the  accompanying  cut.  It  is  thus  described  by  the  author : 
'"Lengthwise,  within,  and  between  the  blades  of  the  beak,  is  a 
steel  tube,  one  end  of  which  is  open,  the  other  solid  and  flat,  and 
jointed  in  a  mortice  in  the  male  part  of  the  joint  of  the  forceps. 
When  the  forceps  are  opened,  this  joint  permits  the  tube  to  fall 
backward  and  forward  from  one  blade  of  the  beak  to  the  other, 
without  any  lateral  motion.  Within  this  tube  is  a  spiral  spring, 
which  forces  a  shaft  up  two-thirds  of  the  tube,  the  other  part  is 
a  well  tapered  or  conical  screw.  *  *  *  *  The  shaft  and  tube 
are  so  fitted  together,  and  to  the  beak  of  the  forceps,  that  one- 
half  of  the  rounded  part  of  the  shaft  projects  beyond  the  end  of 
the  tube,  so  that  the  shaft  may  play  up  and  down  upon  the 
spring  about  half  an  inch,  and  the  screw  or  shaft  be  embraced 
between  the  bla^les  of  the  beak  of  the  instrument." 

Fig.  150. 


The  instrument  here  represented  (see  Fig.  150),  differs  a  little 


MANNER   OF    EXTRACTING    ROOTS    OF   TEETH. 


377 


from  Dr.  Hullihen's  in  the  manner  of  its  construction,  though  it 
acts  upon  precisely  the  same  principle. 

"  The  forceps,"  says  Dr.  H.,  "  are  used  by  first  embracing  the 
shaft  between  the  blades.*  Then  screwing  it  as  gently  and 
deeply  into  the  root  as  possible,  the  blades  are  opened,  and  pushed 
up  on  the  root,  which  is  then  seized  and  extracted.  The  screw 
thus  combined  with  the  forceps,  prevents  the  root  from  being 
crushed.  It  acts  as  a  poAverful  lever  when  a  lateral  motion  is 
given  ;  it  is  likewise  of  advantage  when  a  rotary  motion  is  made ; 
it  prevents  the  forceps  from  slipping  or  from  losing  their  action, 
should  one  side  of  the  root  give  way  in  the  act  of  extracting  it ; 
and  is  used  with  equal  advantage  where  one  side  of  the  root  is 
entirely  gone."    • 

The  opportunities  which  the  author  has  had'  of  testing  the 
value  of  this  instrument,  have  been  sufficient  to  justify  him  in 
stating  that  its  merits  are  not  overrated  by  the  inventor.  Every 
practitioner  would,  therefore,  do  well  to  provide  himself  with 
one  of  them. 


Fig.  151 


For  the  extraction  of  the  roots  of  the  upper  molars,  before 
they  have  become  separated  from  each  other  by  decay,  the  for- 
ceps (Fig.  151),  invented  by  Dr.  Maynard,  will  be  found  highly 
valuable.     The  outer  beak  of  each  instrument  is  brought  to  a 

*  The  author  has  a  pair  constructed  so  that  the  blades  of  the  beak  of  the  forceps 
grasp  the  upper  extremity  of  the  screw  instead  of  the  shaft. 
25 


378  HEMORRHAGE    AFTER    EXTRACTION. 

sharp  point,  for  perforating  the  alveolus  between  the  buccal 
roots,  and  for  securing  between  them  a  firm  hold,  while  the  inner 
beak  is  intended  to  rest  upon  the  edge  of  the  alveolus  and  em- 
brace the  palatine  fang.  By  this  means  a  sufficiently  firm  hold 
is  secured  to  enable  the  operator  to  remove  the  roots  of  an  upper 
molar  without  difficulty.  Two  pairs,  as  represented  in  the  en- 
graving, one  for  the  right  and  one  for  the  left  side  are  required. 
The  advantage  to  be  derived  from  forceps  of  this  description 
must  be  apparent  to  every  dentist. 

EXTRACTIOX  OF  THE  TEMPORARY  TEETH. 

The  temporary  teeth  should  be  extracted  in  the  same  manner 
as  the  permanent,  and  with  the  same  instruments.  If  the  power 
be  properly  directed,  very  little  force  is  required  for  their  re- 
moval ;  because  the  roots  of  these  teeth  have  generally  suffered 
more  or  less  loss  of  substance  before  the  operation  is  called  for ; 
and  when  they  remain,  the  alveolar  processes,  at  this  early  age, 
are  so  soft  and  yielding  as  to  offer  little  resistance  to  the  tooth. 

The  operator  should  be  careful  not  to  injure  the  pulps  of  the 
permanent  teeth,  or  the  jaw-bone.  Serious  accidents  sometimes 
occur  from  an  improper  or  awkward  removal  of  these  teeth. 
But,  as  has  been  before  remarked,  their  extraction  is  seldom  re- 
quired. It  should  only  be  resorted  to  for  the  relief  of  tooth- 
ache, the  cure  of  alveolar  abscess,  to  prevent  irregularity  in  the 
permanent  teeth,  or  in  case  of  necrosis  of  the  socket.  And  even 
in  such  cases,  it  is  necessary  to  exercise  much  judgment  in  de- 
ciding how  far  pain  and  inconvenience  should  be  endured,  rather 
than  extract  the  offending  tooth ;  or  how  far  the  chance  of  in- 
jury to  the  permanent  teeth  demands  the  removal  of  diseased 
milk  teeth.  Their  premature  extraction  is  so  often  followed  by 
a  crowded  state  of  the  permanent  teeth,  that  their  indiscrimi- 
nate removal,  for  trifling  causes,  cannot  be  too  strongly  con- 
demned. 

HEMORRHAGE  AFTER  EXTRACTIOX. 

It  rarely  happens  that  excessive  hemorrhage  follows  the  ex- 
traction of  a  tooth.     Indeed,  it  is  oftener  more  desirable  to  pro- 


HEMORRHAGE    AFTER    EXTRACTION.  379 

mote  bleeding  by  rinsing  the  mouth  with  warm  water  than  to 
attempt  its  suppression.  Nevertheless,  cases  do  sometimes  occur 
in  which  it  becomes  excessive  and  alarming.  It  has  been  known, 
in  some  instances,  to  terminate  fatally;  this,  however,  does  not 
appear  to  be  dependent  upon  the  manner  in  which  the  operation 
is  performed;  but  rather  upon  a  hemorrhagic  diathesis  of  body, 
attributable  to  a  deficiency  in  the  coagulating  property  of  the 
blood.  Hence,  whenever  a  tendency  to  it  exhibits  itself  in  one 
member  of  a  family,  it  is  usually  found  to  exist  in  all.  Of  the 
many  cases  which  have  fallen  under  our  own  observation,  we 
shall  mention  only  the  following: 

In  the  fall  of  1834,  Miss  I.,  fifteen  years  of  age,  had  the  se- 
cond molar  on  the  left  side  of  the  upper  jaw  removed.  The 
hemorrhage,  immediately  after  the  operation,  was  not  greater 
than  usually  occurs,  and  in  the  course  of  half  or  three-quarters 
of  an  hour,  it  ceased  altogether.  But  at  about  twelve  o'clock  on 
the  following  night,  it  commenced  again,  the  blood  flowing  so 
profusely  as  to  excite  considerable  alarm.  A  messenger  was  im- 
mediately sent  to  ask  our  advice,  and  we  directed  that  the  alveo- 
lar cavities  should  be  filled  Avith  pledgets  of  lint,  saturated  with 
tincture  of  nut-galls.  Two  days  after,  at  about  six  o'clock  in 
the  morning,  we  were  hastily  sent  for  by  the  young  lady's  mo- 
ther, and  when  we  arrived  at  her  residence,*were  informed  that 
the  bleeding  had  then  been  going  on  for  about  four  hours.  Dur- 
ing this  time  more  than  two  quarts  of  blood  had  been  discharged. 
The  blood  was  still  oozing  very  fast.  After  we  had  removed  the 
coagulum,  we  filled  the  socket  with  pieces  of  sponge,  saturated, 
as  the  lint  had  been,  with  tincture  of  nut-galls.  When  firmly 
pressed  in,  and  secured  by  a  compress,  the  hemorrhage  ceased. 
These  were  permitted  to  remain  until  they  were  expelled  by  the 
suppurative  and  granulating  processes.  We  afterwards  had  oc- 
casion to  extract  one  tooth  for  a  sister  and  two  for  the  mother 
of  the  young  lady;  and  a  hemorrhage,  similar  to  that  just  de- 
scribed, occurred  in  each  case. 

We  have  had,  perhaps,  some  thirty  or  forty  cases  of  this  de- 
scription, but  never  found  it  necessary,  except  in  one  instance, 
to  adopt  any  other  course  of  treatment  than  that  described  in 
the  case  just  narrated.  More  powerful  remedies,  however,  are 
sometimes  employed.  Some  use  a  solution  of  the  sulphate  of  copper, 


380  HEMORRHAGE    AFTER    EXTRACTION. 

or  of  the  nitrate  of  silver,  •while  others  employ  the  actual  cau- 
tery. Tannic  acid  is  an  excellent  styptic,  and  will  answer  well, 
in  combination  with  the  compress  of  lint  or  cotton,  for  most 
cases.  For  more  obstinate  cases  the  per-sulphate  of  iron  will  be 
found  to  be  the  most  potent  styptic  of  the  materia  medica.  But 
if  pressure  be  so  applied  as  to  act  directly  upon  the  mouths  of 
the  bleeding  vessels,  it  will  almost  always  arrest  the  hemorrhage. 
The  author  has,  in  two  cases,  found  it  necessary  to  have  recourse 
to  the  actual  cautery. 

The  following  case  is  quoted  by  Dr.  Fitch  from  Le  Dentiste 
Observateur,  par  H.  G.  Courtois,  Paris,  1775: 

"A  person  living  in  Paris  called  on  me  to  extract  a  canine 
tooth  for  him.  On  examining  his  mouth,  I  thought  that  the  man 
was  attacked  with  scurvy ;  but  this  did  not  seem  sufficient  to 
hinder  the  patient  from  having  his  tooth  extracted  ;  nor  would  he 
consent  to  its  remaining  on  account  of  the  pain  which  it  gave 
him.  After  the  tooth  was  extracted,  it  did  not  appear  to  me 
that  it  bled  more  profusely  than  is  customary  after  similar  ope- 
rations. The  following  night  I  was  called  upon  to  see  the  pa- 
tiSnt,  who  had  continued  to  bleed  ever  since  he  left  me.  I 
employed,  for  stopping  this  hemorrhage,  agaric  from  the  oak 
bark,  which  I  commonly  used  with  success.  The  following  day 
I  was  again  sent  fot ;  the  bleeding  still  continued.  After  having 
disburdened  the  mouth  of  all  the  lint-pledgets,  which  I  used  for 
making  compression  at  the  place  where  the  blood  appeared  to 
come  from,  I  made  the  patient  take  some  mouthfuls  of  water  to 
clear  his  mouth  of  all  the  clots  of  blood  with  which  it  was  filled  ;  I 
perceived,  then,  that  the  blood  came  no  longer  from  the  place  where 
I  had  extracted  the  tooth,  but  from  the  gums ;  there  was  not  a 
single  place  in  the  whole  mouth  from  which  the  blood  did  not 
issue.  I  called  in  the  physician,  who  ordered  several  bleedings 
in  succession,  besides  astringents,  taken  internally;  and  gargles 
of  the  same  nature ;  but  all  these  attempts  to  improve  the  coagu- 
lability of  the  blood  were  made  to  no  purpose.  It  was  not  pos- 
sible to  stop  the  hemorrhage.  The  patient  died  the  ninth  or 
tenth  day  after  the  extraction  of  the  tooth." 

Mr.  Snell  mentions  a  similar  case,  which  also  terminated 
fatally. 


CHAPTER   ELEVENTH 


THE  USE  OF  ANAESTHETIC  AGENTS  IN  THE  EXTRACTION 

OF  TEETH. 


Of  the  various  agents  that  hav-e  been  employed  for  the  pre- 
vention of  pain  during  surgical  operations,  sulphuric  aether 
and  chloroform  have  proved  more  successful  and  been  more  gene- 
rally used  than  any  others.  The  practicability  of  producing 
anaesthesia  with  the  former  was  first  brought  prominently  before 
the  medical  and  dental  profession  in  1846,  by  Dr.  W.  G.  S. 
Morton,  dentist,  of  Boston,  Mass.;  and  with  the  latter,  in  1847, 
by  Professor  J.  Y.  Simpson,  of  Edinburgh,  Scotland.  The  anaes- 
thetic effect  is  obtained  by  inhalation  of  the  vapor,  and  is  sup- 
posed to  be  nothing  more  than  a  transient  state  of  intoxication, 
which  usually  disappears  almost  immediately  after  the  discontin- 
uance of  the  administration,  though  in  many  cases  it  has  proved 
fatal.  For  this  reason,  we  do  not  think  that  agents  capable  of 
producing  such  powerful  and  dangerous  effects  as  aether  and 
chloroform,  should  be  used  in  so  simple  an  operation  as  the  ex- 
traction of  a  tooth.  The  first,  however,  is  less  dangerous  than 
the  second;  but  its  anaesthetic  effect  is  less  certain  and  prompt, 
from  seven  to  ten  minutes  being  usually  required,  whereas  with 
the  other,  it  is  obtained  in  from  thirty  seconds  to  two  minutes. 
When  aether  is  used,  from  six  to  ten  or  fifteen  ounces  are  em- 
ployed; but  with  chloroform,  it  is  rarely  necessary  to  administer 
more  than  from  thirty  to  one  hundred  and  fifty  drops.  What 
we  have  said  about  sulphuric  aether  applies  equally  to  chloric 
aether,  a  substance  very  extensively  used,  if  not  first  proposed, 
by  the  late  Professor  Warren,  of  Boston. 

A  number  of  instruments  have  been  gotten  up  for  the  inhala- 
tion of  the  vapor  of  these  agents,  but  the  simplest  and,  we  think, 
the  best  method  of  administration  is  from  a  hollow  sponge,  a 
napkin,  or  a  pocket-handkerchief. 

It  may  not  always  be  possible,  for  any  one,  in  the  adminis- 


382  USE   OF    ANAESTHETIC    AGENTS 

tration  of  either  of  the  foregoing  agents  even  to  a  person  sup- 
posed to  be  free  from  any  special  proclivity  to  disease  from  or- 
ganic derangement,  to  pronounce,  a  priori,  that  no  bad  effect 
will  result  from  it ;  but  all  agree  that  it  is  unsafe  to  give  it  to  a 
patient  laboring  under  disease  of  the  heart,  brain,  or  lungs. 
The  practitioner,  therefore,  whether  medical  or  dental,  should 
be  well  assured,  before  giving  sether  or  chloroform,  and  especially 
the  latter,  that  these  organs  are  not  only  free  from  disease,  but 
also  from  any  morbid  tendency,  as  ignorance  with  regard  to 
this  matter  might  lead  to  fatal  consequences.  It  should  be  given 
cautiously  under  any  circumstances,  and  the  pulse  should  never 
be  permitted  to  fall,  during  the  inhalation,  below  sixty,  or  at 
most,  fifty-five  beats  a  minute  ;  but  if  from  carelessness  or  any 
other  cause,  the  patient  should  sink  and  the  pulsation  cease,  the 
agent  should  be  immediately  removed  from  the  mouth,  and  if 
occupying  a  sitting  posture,  he  shoiild  be  placed  in  a  reclining 
position,  air  freely  admitted,  cold  water  dashed  in  the  face,  the 
feet  and  hands  rubbed  with  hot  salt  or  mustard,  and  if  necessary, 
artificial  respiration  made  and  galvanism  applied.  In  addition 
to  these  means  the  tongue  should  be  depressed  and  drawn  for- 
ward by  a  finger  thrust  deeply  into  the  mouth,  as  recommended 
by  Ricord ;  or  Dr.  Marshall  Hall's  '^  ready  method"  may  be 
faithfully  and  patiently  practised. 

It  is  thought  by  those  who  have  had  most  experience  in  the 
use  of  {ether  and  chloroform  as  anaesthetic  agents,  that  their 
administration  is  attended  with  less  danger  when  the  patient  is 
in  a  reclining  than  when  in  a  sitting  posture.  It  would  be  well, 
therefore,  when  either  is  used  preparatory  to  the  extraction  of 
teeth,  to  place  the  patient  as  nearly  as  possible  in  such  a  posi- 
tion ;  when  the  dentist  is  provided  with  an  operating  chair 
having  a  movable  back  this  can  be  very  readily  done. 

Suspension  of  nervous  sensibility,  induced  by  inhaling  the 
vapor  of  the  above  mentioned  agents — or  amylen,  a  more  recently 
discoved  anassthetic — is  general,  every  part  of  the  body  being 
affected  alike  ;  but  partial  or  local  anaesthesia  may  be  procured 
by  other  and  less  dangerous  means.  Congelation  or  freezing, 
first  proposed  and  employed  in  the  Charity  Hospital,  Paris,  by 
an  interne  of  M.  Velpeau,  and  subsequently  recommended  by 
Dr.  James  Arnott,  of  London,  has  been  resorted  to  for  several 


IN  THE  EXTRACTION  OF  TEETH.  383 

years,  both  by  surgeons  and  dentists,  and  practiced  to  a  limited 
extent,  with  some  success.  This  may  be  effected  by  applying  a 
mixture  of  pounded  ice  and  common  salt  in  the  proportion  of 
two  or  three  parts  of  the  former  to  one  of  the  latter,  to  the  part 
on  which  the  operation  is  to  be  performed.  But  in  the  use  of  this, 
care  is  necessary  to  prevent  reducing  the  temperature  too  much, 
as  in  this  case,  loss  of  vitality  would  be  occasioned  by  it.  We 
have  heard  of  a  few  cases  in  which  this  has  occurred,  but  we 
believe  it  was  owing  in  every  instance  to  carelessness  or  want 
of  judgment  on  the  part  of  the  operator,  as  to  the  length  of  time 
the  application  of  the  mixture  should  be  continued. 

Several  instruments  have  been  invented  for  the  application  of 
the  freezing  mixture  to  teeth  preparatory  to  extraction.  The 
one  which  we  consider  best  adapted  for  the  purpose,  was  de- 
signed by  Dr.  Branch,  of  Chicago,  111.  It  consists  of  a  hollow 
tube  about  an  inch  or  a  little  more  in  diameter,  with  about 
five-eighths  of  an  inch  cut  out  at  one  end  on  either  side  that  it 
may  readily  be  placed  over  a  tooth.  To  this  is  attached  a  sac 
of  finely  prepared  membrane  large  enough  to  hold  a  table- 
spoonful  of  the  mixture.  The  hollow  of  the  tube  is  occupied  by 
a  steel  wire  spiral  spring.  Just  before  using  it  a  sufficient 
quantity  of  the  freezing  mixture  is  put  in  the  tube ;  the  end  of 
the  latter  is  placed  over  the  tooth,  when  the  ice  and  salt  are 
forced  up  gently  around  it  by  pressing  on  the  spring  at  the  other 
extremity  of  the  instrument.  Two  tubes  are  employed ;  one 
straight  for  teeth  in  the  anterior  part  of  the  mouth,  the  other 
bent  near  one  end,  for  the  more  convenient  application  of  the 
mixture  to  a  molar  tooth. 

The  sudden  application  of  such  intense  cold  to  a  sensitive 
tooth,  or  to  one  which  has  not  lost  its  vitality,  is  often  productive, 
at  first,  of  severe  pain  ;  on  this  account,  many  object  to  the  use 
of  it,  preferring  the  momentary  suffering  consequent  upon  the 
operation  of  extraction  than  that  occasioned  by  the  freezing 
mixture.  But  this  effect  is  rarely  experienced  in  its  use  on  dead 
teeth  or  the  roots  of  teeth  which  have  lost  their  vitality ;  hence, 
the  application  of  it  has  to  such  proved  more  satisfactory  than  to 
living  teeth. 

With  the  view  of  obviating  the  above  objection  to  the  use  of 
cold  as  an  anaesthetic  agent,  Messrs.  Home  and  Thornthwaite, 


384  USE    OF   ANJ^vSTHETIC    AGENTS 

opticians,  at  the  suggestion  of  Mr.  Blundell,  dentist,  of  London, 
contrived  and  constructed  an  apparatus,  by  which  the  tempera- 
ture may  be  gradually  diminished  ;  say  from  98°  or  blood  heat, 
down  to  zero,  or  any  required  degree,  thus  preventing  the  pain 
consequent  upon  the  sudden  application  of  the  freezing  agent. 
The  apparatus  is  thus  described.  "  The  required  amount  of 
■water  is  cooled  down  by  means  of  ice  and  salt  to  about  zero,  in 
a  vessel  called  the  refrigerator.  To  this  vessel  is  attached 
another,  called  a  graduator,  containing  warm  water  at  about 
100°,  and  so  constructed  as  to  allow  the  slow  admixture  of  its 
contents  with  the  chilled  water  in  the  refrigerator,  and  thus  pro- 
duce a  gradually  diminishing  temperature,  for  the  purpose  of 
preventing  sudden  shock  and  pain  to  the  teeth,  which  a  direct 
application  of  cold  would  inevitably  cause.  A  tube  conveys  this 
graduating  current  into  a  terminal  portion  constructed  of  very 
fine  membrane,  which  adapts  itself  to  the'form  of  the  gums,  and 
wholly  surrounds  the  tooth  to  be  withdrawn.  The  fluid  then 
passes  away  through  an  exit  tube.  In  this  manner  a  constant 
current  of  cold,  at  a  decreasing  temperature,  is  made  to  pass 
over  the  part,  abstracting  therefrom  all  heat,  and  with  it  the 
power  of  feeling."  The  gum  and  alveolar  membrane  being  now 
in  a  frozen  condition,  and,  consequently,  devoid  of  sensibility, 
the  extracting  instrument  is  applied  and  the  tooth  removed. 

It  would  seem,  from  all  that  has  been  said  of  this  contrivance, 
that  it  is  admirably  adapted  to  the  purpose  for  which  it  was 
designed. 

In  the  early  part  of  the  year  1858,  Mr.  J.  B.  Francis,  dentist, 
of  Philadelphia,  announced  the  discovery  of  an  original  method 
of  producing  local  anaesthesia,  said  to  be  peculiarly  applicable  to 
the  extraction  of  teeth  Avhich  consists  in  passing  an  electro- 
galvanic  current  through  the  tooth  at  the  moment  of  its  removal. 
The  discovery  was  submitted  to  the  Franklin  Institute,  Philar 
delphia,  and  the  committee  to  whom  it  was  referred  for  exami- 
nation, composed  in  part  of  dentists,  reported  favorably  in  regard 
to  the  claims  of  the  inventor.*    One  of  the  members  of  this  com- 

*  The  following  is  an  extract  from  the  report  referred  to  above.  "  The  Committee 
is  satisfied,  from  the  observation  and  experiment  of  its  members,  that  in  a  large  ma- 
jorit}'  of  cases  of  extraction  with  this  apparatus,  no  pain  whatever  is  felt  by  the 
patient. 

"  To  test  the  question  whether  the  effect  might  not  be  simply  mental,  the  circuit  was 


IN    THE    EXTRACTION    OF   TEETH.  385 

mittee,  W.  S.  Wilkinson,  states  that  he  had  extracted  between 
four  and  five  hundred  teeth,  applying  the  electric  current ;  and 
that  in  ninety-five  per  cent,  of  the  cases  it  was  done  without 
pain  to  his  patient.- 

The  method  of  applying  it  is  very  simple.  One  pole  (the 
negative  is  preferable)  of  the  electro-galvanic  machine  is  attached 
to  one  of  the  handles  of  the  forceps  by  means  of  a  flexible  con- 
ductor, while  the  metallic  handle  of  the  other  is  grasped  by  the 
patient ;  the  power  of  the  current  being,  previously  to  the  opera- 
tion, graduated  by  the  piston  of  the  coil,  while  the  patient  holds 
the  forceps  in  the  other  hand.  The  current  should  only  be 
suflficiently  powerful  to  be  distinctly  felt.  The  circuit  through 
the  tooth  is  not  made  until  at  the  instant  the  operation  begins. 
The  closing  and  breaking  of  the  galvanic  circuit  is  managed 
either  by  the  foot  of  the  operator  or  by  an  assistant. 

A  small  electro-galVanic  battery,  arranged  for  this  purpose, 
having  been  placed  in  the  office  of  the  author,  soon  after  the 
announcement  of  the  discovery,  he  has  had  frequent  opportuni- 
ties of  applying  this  new  agent  in  the  extraction  of  teeth. 
Thus  far,  about  nine  out  of  ten  of  those  who  were  placed  under 
its  influence,  while  undergoing  the  operation,  assured  him  that 
they  either  experienced  no  pain  at  all,  or  only  very  little — not 
a  tenth  part  of  what  they  had  experienced  under  the  operation 
on  former  occasions.  In  almost  every  case  in  which  the  tooth 
was  grasped,  allowing  the  instrument  to  come  in  contact  with 
only  the  edge  of  the  gum,  the  operation  appeared  to  be  painless, 
or  nearly  so.  But  when  pushed  up  a  considerable  distance 
between  it  and  the  tooth,  the  suffering  was  not  apju-eciably 
diminished,  the  electric  current  in  such  cases  seeming  to  be  too 
much  diffused.  It  is  stated  by  those  who  have  made  the  experi- 
ment, that  this  diffusion  of  the  electric  current  may  be  prevented 

broken  without  the  patient  being  aware  of  it,  when  the  usual  pain  was  experienced, 
although,  in  the  same  patient,  and  on  the  same  occasion,  teeth  had  been  removed 
while  the  current  was  flowing  without  causing  pain. 

"  In  the  less  successful  cases,  the  teeth  were  broken  and  diseased  below  the  level  of 
the  gum,  and  the  pain,  in  adjusting  the  forceps  previous  to  the  completion  of  the  cir- 
cuit and  the  extraction,  was  considerable. 

"  The  sensation  produced  by  the  passage  of  the  current  is  not  painful,  it  being  so 
adjusted  as  to  be  just  perceptible  to  the  patient.  The  committee  believes  its  use  to 
be  entirely  without  danger,  and  not  likely  to  be  followed  by  any  unpleasant  after 
effects." 


386  USE    OF    ANESTHETIC    AGENTS,    ETC. 

by  insulating  the  outer  portion  of  the  instrument  with  a  coating 
of  gutta-percha  or  by  japanning.  The  author  has  not  tried  this 
expedient. 

How  it  is  that  the  passage  of  an  electric  current  through  a 
tooth  should  prevent  pain,  may  be  explained  by  supposing  the 
subtle  fluid  to  exhaust  the  sensibility  of  the  nerves  of  the  parts 
comprised  in  the  operation;  and  that  it  does  in  a  majority  of 
cases,  is  attested  by  many  who  have  been  placed  under  its 
influence.  It  may  be  nothing  more  than  a  mere  substitution  of 
one  sensation  for  another :  but  whether  its  application  will  be- 
come general,  or  its  efficacy  as  an  anaesthetic  agent  be  fully 
established,  remains  for  future  experience  to  settle. 

The  experience  of  the  profession,  up  to  1863,  may  be  briefly 
summed  up  thus :  In  one-fourth  of  the  cases  it  relieves  or 
neutralizes  the  peculiar  pain  of  extraction,  in  one-half  it  has  but 
little  eff"ect,  and  in  the  remaining  fourth  it'very  decidedly  aggra- 
vates the  pain.  It  has,  however,  the  advantage  over  chloroform 
and  the  freezing  process,  of  being  without  any  serious  sequelae. 

As  the  use  of  anaesthetic  agents  of  any  kind  in  the  extraction 
of  teeth  is  attended  with  inconvenience,  nearly  always  delaying 
the  operation,  the  author  is  of  opinion  that  their  employment,  as 
a  general  thing,  should  be  dispensed  with.  He  never  encourages 
their  use,  and  rarely  finds  it  necessary  to  employ  them.  In  the 
case  of  females  with  a  highly  nervous  organization,  it  may  now 
and  then  be  advisable  to  give  a  temporary  courage  to  endure 
pain  by  the  administration  of  a  teaspoonful  of  brandy.  But  we 
have  found  less  trouble  with  delicate  females  than  with  stalwart 
men  ;  and  to  the  latter  we  certainly  would  never  advise  this  use 
of  stimulants.  Indeed  the  extraction  of  a  tooth  is  so  simple  an 
operation,  seldom  requiring  more  than  from  two  to  five  seconds 
for  its  performance,  that  most  persons  should  rather  submit  to  it 
at  once,  than  have  it  protracted  by  the  application  of  an  agent 
for  the  prevention  of  the  momentary  pain  which  it  occasions. 


CHAPTER    TWELFTH. 
ATROPHY  OF  THE  TEETH. 

That  peculiar  structural  alteration  of  the  teeth,  designated 
atrophy,  is  less  frequent  in  its  occurrence  than  any  other  disease 
to  which  these  organs  are  liable;  but  as  the  progress  of  the 
affection  usually  terminates  with  the  action  of  the  causes  con- 
cerned in  its  production,  it  has  scarcely  been  deemed  of  sufficient 
aportance  to  merit  serious  consideration.  Hence  its  aetiology 
and  pathology  have  not  been  very  carefully  investigated.  In- 
deed most  writers  upon  the  diseases  of  the  teeth  have  overlooked 
the  affection  altogether ;  while  a  few  have  merely  alluded  to  it, 
without  describing  the  characteristics  of  even  its  principal  varie- 
ties. Whether  we  shall  now  be  able  to  throw  any  additional 
light  upon  the  subject,  or  establish  the  correctness  of  any 
opinions  already  advanced,  we  leave  to  others  to  determine. 

The  strict  applicability  of  the  term  atrophy  may,  perhaps,  be 
considered  as  somewhat  questionable ;  as  the  two  principal  varie- 
ties of  the  affection  consist  in  a  congenital  defect  in  some  portion 
of  the  enamel  of  two  or  more  teeth,  rather  than  in  the  wasting, 
from  want  of  nourishment,  of  any  of  the  dental  tissues.  This 
term  would  seem  to  be  rendered  still  more  inappropriate  by  the 
fact,  that  neither  of  the  varieties  to  which  we  have  referred 
occurs  subsequently  to  the  formation  of  the  enamel.  But  as  the 
congenital  form  of  the  disease  is  evidently  the  result  of  altered 
function  in  a  portion  of  one  or  more  of  the  formative  organs — if 
not  of  absolute  dco-eneration,  from  vicious  nutrition — we  are 
disposed  to  regard  the  term  as  the  most  applicable  of 'any  that 
can  be  applied  to  it. 

Mr.  Fox  speaks  of  a  defect,  sometimes  met  with  in  the  organi- 
zation of  the  enamel,  which  he  terms  honey-combed,  characterized 
by  a  yellow  color,  and  a  great  number  of  indentations  upon  its 
surface,  giving  to  the  teeth  the  appearance  of  "  the  exterior  of 
a  sponge."     He  refers  these  defects  to  a  deviation  from  the 


388  ATROPHY  OF  THE  TEETH. 

natural  action  of  the  membrane  which  secretes  the  enamel,  de- 
pendent upon  some  "peculiarity  of  constitution,"  during  the 
first  months  of  infancy.  He  thinks  it  is  liable  to  occur  in  seve- 
ral children  of  the  same  family,  and  that  teeth  thus  affected  are 
less  liable  to  decay  than  those  which  have  beautiful  and  trans- 
parent enamel.* 

M.  Delabarre,  an  ingenious  physiologist,  and  for  the  most  part 
a  close  and  very  accurate  observer,  has,  probably,  approached 
nearer  to  a  correct  explanation  of  the  true  cause  of  odontatro- 
phia  than  any  other  writer.  But  he  has  given  to  one  of  the 
varieties — consisting  of  perforations  of  the  enamel — the  im- 
proper term  erosion,  which  is  an  entirely  distinct  affection.  His 
other  variety  —  consisting  of  discoloration  and  deficiency  of 
enamel — he  has  correctly  named  atrophy.  The  latter  he  thinks 
invariably  congenital;  while  the  former,  erroneously  termed 
erosion,  he  believes  may  be  either  congenital  or  accidental. 
Believing  the  doctrine  of  Hunter,  Jourdain,  Fox,  and  Cuvier,  as 
to  the  formation  of  enamel,  to  be  erroneous,  Mons.  Delabarre 
asserts  that  "  this  portion  of  a  tooth  is  formed  from  an  immense 
number  of  exhalants  which  cover  the  crown,  forming  a  sort  of 
imperceptible  velvet;"  which  in  fact  correspond  exactly  with  the 
corpuscles  or  fibres  of  the  enamel  membrane  of  Raschkow. 
These  he  regards  as  integral  parts  of  the  tooth,  and  believing 
the  enamel  fibres  to  be  secreted  by  them,  he  ascribes  the  affec- 
tion under  consideration  to  their  vicious  development  or  imper- 
fect nutrition. 

Lefoulon  adopts  the  views  and  almost  the  precise  language  of 
Delabarre,  in  the  description  which  he  gives  of  the  affection. 
Maury  treats  of  atrophy  and  erosion  as  one  and  the  same  dis- 
ease. But  in  describing  atrophy  he  notices  the  distinctive  pecu- 
liarities by  which  each  affection  is  characterized. f  In  describing 
the  difference  between  erosion  and  atrophy,  M.  Delabarre  says, 
the  part  atrophied  is  deformed  and  deprived  of  the  enamel,  and 
that  the  teeth  are  yellow  and  sensitive,  the  touch  of  the  finger 
causing  pain  :  but  in  erosion,  if  the  crystals  of  the  enamel  are 
not  wholly  destroyed,  the  bottom  of  the  pits  are  of  a  white  color, 

*  Natural  History  and  Diseases  of  the  Human  Teeth;  American  edition,  pages  57, 
58  and  59. 
fTraite  Complet  de  I'Art  du  Dentiste,  pp.  99  and  100. 


ATROPHY  OF  THE  TEETH.  389 

and  on  being  touched  no  disagreeable  sensation  is  experienced ; 
if,  on  the  contrary,  the  crystals  are  destroyed  to  the  dentil^  the 
part  thus  denuded  is  irritable. 

In  an  article  on  erosion,  Maury  gives  a  very  accurate  descrip- 
tion of  several  varieties  of  atrophy  of  the  teeth.  The  first,  he 
represents  as  consisting  of  deep  irregular  white,  or  light  yellow 
spots,  situated  in  the  enamel  of  the  tooth,  without  aifecting  the 
smoothness  of  its  surface.  The  second,  as  characterized  by  small 
crowded  holes,  or  irregular  depressions,  resembling  quilting  ;  or 
as  consisting  of  transverse  sinuosities,  single  or  divided  by  pro- 
minent lines,  which  are  sometimes  "  yellow,  but  of  the  color  of 
the  enamel."  The  third  variety  affects  the  dentine  as  well  as 
the  enamel,  reducing  the  dimensions  of  the  crown  of  the  tooth 
sometimes  to  one-third  its  natural  size,  and  not  unfrequently  di- 
viding it  by  a  deep  circular  groove  or  depression. 

None  of  the  phenomena  here  described  are  produced  by  the 
action  of  corrosive  agents,  or  are  the  result  of  chemical  decom- 
position either  of  the  enamel  or  dentine,  but  are  manifestly  de- 
pendent upon  other  causes.  The  term  erosion,  therefore,  cannot 
with  propriety  be  applied  to  either  variety  of  the  affection  just 
noticed.  Although  Maury  has  given,  under  the  term  erosion,  a 
better  description  of  the  principal  varieties  of  dental  atrophy 
than  any  other  writer,  he  has  omitted  some  things  which  it  will 
be  proper  to  mention.  In  treating  of  these  different  varieties, 
therefore,  we  shall  change,  somewhat,  the  order  in  which  he  has 
arranged  them. 

Odontatrophia  may  very  properly  be  divided  into  three  vari- 
ties.  Each  has  characteristic  peculiarities  which  distinguish  it 
from  either  of  the  others.  Two  are  always  congenital,  and  the 
other,  although  most  frequently  congenital,  sometimes  occurs 
subsequently  to  the  eruption  o^the  tooth. 

First  variety.  The  peculiarities  that  distinguish  this  variety 
of  atrophy  from  either  of  the  others  are,  that  it  never  impairs 
the  uniformity  and  smoothness  of  the  surface  of  the  enamel,  and 
is  characterized  by  one  or  more  white,  or  dark  or  light  brown, 
irregularly  shaped  spots,  upon  the  labial  or  buccal  surface  of  the 
tooth.  It  occurs  oftener  than  the  third  variety,  and  less  fre- 
quently than  the  second.  It  rarely  appears  on  more  than  one 
or  two  teeth  in  the  same   mouth,  though  several  are  sometimes 


390  ATROPHY  OF  THE  TEETH. 

marked  by  it.  It  is  seen  on  the  molars  more  frequently  than 
the^Mcuspids,  and  much  oftener  on  the  incisors  of  the  upper 
jaw  than  any  of  the  other  teeth.  We  do  not  recollect  to  have 
ever  observed  it  on  the  cuspids  of  either  jaw,  nor  on  the  palatine 
or  lingual  surfaces  of  the  incisors. 

The  enamel  is  much  softer  on  the  affected  than  on  the  un- 
affected parts  of  the  tooth,  and  may  be  easily  broken  and  reduced 
to  powder  with  a  steel  instrument.  It  seems  to  be  almost  wholly 
deprived,  in  these  places,  of  its  animal  constituents,  and  to  have 
lost  its  connection  with  the  subjacent  dentine.  The  size  of  the 
atrophied  spots  are  almost  as  variable  as  their  shape,  but  the 
only  harm  resulting  from  them,  is  the  unsightly  aspect  they 
sometimes  give  to  the  tooth. 

As  we  have  before  remarked,  this  variety  of  atrophy  is  some- 
times accidental,  occurring  subsequently  to  the  eruption  of  the 
tooth,  but  in  a  large  majority  of  the  cases  it  is  congenital.  It  is 
rarely  seen  on  a  temporary  tooth.  In  all  the  cases  which  have 
come  under  our  observation  it  was  confined,  to  the  best  of  our 
recollection,  to  the  teeth  of  second  dentition. 

Second  variety.  This  may  be  very  properly  denominated  j^er- 
f orating  or  fitting  atrophy  ;  it  gives  to  the  enamel  an  indented 
or  pitted  appearance,  the  irregular  depressions  or  holes  extend- 
ing transversely  across  and  around  the  tooth.  The  pits  are 
sometimes  more  or  less  distinctly  separated  one  from  another,  by 
prominent  lines ;  at  other  times  they  are  confluent,  and  form  an 
irregular  horizontal  groove.  Sometimes  they  penetrate  but  a 
short  distance  into  the  enamel  ;  at  other  times  they  extend  en- 
tirely through  it  to  the  dentine.  Their  surface,  though  generally 
rough  and  irregular,  usually  presents  a  glossy  and  polished  ap- 
pearance— a  peculiarity  which  always  distinguishes  this  variety 
of  the  affection  from  erosion.  The  pits  often  have  a  dark  brown- 
ish appearance,  though  sometimes  they  have  the  same  color  as 
the  enamel  on  other  parts  of  the  tooth. 

This  variety  of  atrophy  is  never  confined  to  a  single  tooth. 
Two,  four,  six  or  more  corresponding  teeth  are  always  aflFected 
at  the  same  time,  in  each  jaw ;  and  the  corresponding  teeth  on 
either  side  precisely  in  the  same  manner,  and  in  the  same  place. 
When  more  than  two  are  marked,  the  distance  of  the  pits  from 
the  coronal  extremity  of  the  tooth  varies,  according  to  the  pro- 


ATROPHY    OF    THE    TEETH.  391 

gress  made  in  the  formation  of  the  enamel  at  the  time  of  the 
operation  of  the  causes  concerned  in  the  production  of  the  affec- 
tion. For  example,  when  the  line  of  pits  in  the  central  iffcisors 
is  situated  about  two  lines  from  their  cutting  edges,  it  will  scarce- 
ly be  one  line  from  the  cutting  edges  of  the  laterals,  and  only 
the  points  of  the  cuspids  will  be  marked.  When  the  indenta- 
tions are  nearer  the  edges  of  the  central  incisors,  they  will  be  on 
the  edges  of  the  laterals,  and  the  cuspids  will  have  entirely 
escaped. 

Sometimes  the  teeth  are  marked  with  two  or  three  rows  of 
pits,  and  when  this  is  the  case,  the  patient  has  either  had  two  or 
three  relapses  ;  or  has  been  attacked  two  or  three  times  in  suc- 
cession with  some  disease  capable  of  interrupting  the  progress  of 
the  formation  of  the  enamel. 

Although  the  incisors  are  more  frequently  marked  with  these 
indentations  than  any  of  the  other  teeth,  the  cuspids,  bicuspids, 
and  even  the  molars  are  sometimes  aifected  with  them.  When 
the  disease  attacks  the  molars,  its  effects  are  generally  located 
on  the  grinding  surface.  The  permanent  teeth  are  more  liable 
to  be  attacked  than  the  temporary.  We  have  known  but  one 
instance  in  Avhich  the  latter  were  affected  with  the  disease. 

This  variety  of  atrophy  occurs  oftener  than  either  of  the  others, 
and  though  it  sometimes  gives  to  the  teeth  a  disagreeable  and 
unsightly  appearance,  it  rarely  increases  their  liability  to  decay. 

Third  variety.  In  this  variety  of  atrophy  the  whole  or  only 
a  part  of  the  crown  of  a  tooth  may  be  affected  ;  the  dentine  being 
often  implicated  as  well  as  the  enamel.  The  tooth  usually  has 
a  pale  yellowish  color,  a  shriveled  appearance,  and  is  partially 
or  wholly  divested  of  enamel.  Sometimes  the  crown  is  not  more 
than  one-half  or  one-third  its  natural  size.  Its  sensibility  is 
usually  much  increased,  and  its  susceptibility  to  pain  from  exter- 
nal impressions  is  wonderfully  excited  by  acids.  It  is  also  more 
liable  than  the  other  teeth  to  be  attacked  by  caries.  The  root 
of  the  tooth  is  sometimes,  though  rarely,  affected,  and  presents 
an  irregular  knotted  appearance. 

The  disease  is  often  confined  to  a  single  tooth,  but  it  more  fre- 
quently shows  itself  on  two  corresponding  teeth  in  the  same  jaw. 
According  to  our  observation,  the  bicuspids  are  more  liable  to 
be  attacked  than  any  of  the  other  teeth.     The  temporary  teeth 


392         CAUSES  OF  ATROPHY  OF  THE  TEETH. 

are  rarely  aifected  with  it.  This  variety  of  atrophy  occurs  less 
frequently  than  either  of  the  others  ;  and  although  it  increases 
the  liability  of  the  affected  organs  to  caries,  they  sometimes 
escape  until  the  twentieth  or  thirtieth  year  of  age. 

In  the  description  which  we  have  given  of  the  three  varieties 
of  dental  atrophy,  we  may  have  omitted  to  mention  some  of  the 
peculiarities  belonging  to  each,  but  w^e  have  pointed  out  their 
principal  characteristics  with  sufficient  accuracy  to  enable  them 
to  be  dii^tinguished  one  from  another,  and  either  from  erosion. 

CAUSES. 

The  first  variety  is  evidently  produced  by  some  cause  capable 
either  of  preventing  or  destroying  the  bond  of  union  between 
the  enamel  and  subjacent  dentine,  but  what  that  cause  is,  be- 
comes a  question  which  it  may  be  difficult  to  answer.  Subse- 
quently to  the  eruption  of  the  teeth,  it  may  be  occasioned  by 
mechanical  violence,  but  we  have  never  known  more  than  one 
case  in  which  it  had  resulted  from  this  cause,  and  that  was  occa- 
sioned by  a  blow  upon  the  tooth. 

Now,  whether  the  bond  of  union  between  this  portion  of  the 
enamel  and  the  subjacent  dentine  was  immediately  destroyed  by 
the  concussion  of  the  blow,  or  whether  it  resulted  from  subse- 
quent inflammation  and  the  death  of  the  intermediate  membrane, 
is  a  question  which  may  not  be  easily  answered.  If  it  were  de- 
stroyed at  once  by  the  blow,  one  might  be  led  to  suppose  that 
the  change  in  the  color  of  the  enamel  would  have  been  observed 
immediately ;  but  it  may  have  resulted  from  some  subsequent 
change  or  alteration  in  the  animal  constituents  of  this  part  of 
the  enamel,  following  as  a  consequence  of  the  injury  produced 
by  the  violence  of  the  blow.  These  are  questions,  however, 
which  the  present  state  of  our  knowledge  does  not  enable  us  to 
solve.  But  that  the  white  spot  in  this  case  resulted  as  a  conse- 
quence of  the  blow,  there  cannot  be  the  least  shadow  of  doubt. 

\V  hen  the  aflfection  is  congenital,  as  it  almost  always  is,  it  is 
dependent  upon  some  other  cause;  possibly  upon  disease  in  the 
pulp,  or  intermediate  membrane,  which  constitutes  the  bond  of 
union  between  the  dentine  and  enamel,  subsequently  to  the  for- 
mation of  the  latter.     But  what  the  determining  cause  is  of  the 

I 


CAUSES    OF    ATROPHY    OF    THE    TEETH.  393 

disease,  whether  produced  in  this  way  by  simple  local  irritation, 
or  by  general  constitutional  disturbance,  we  are  not  prepared  to 
say.  One  would  be  likely  to  suppose,  if  the  atrophied  spots 
were  occasioned  by  disease  of  the  pulp  or  intermediate  mem- 
brane, the  morbid  action  would  scarcely  confine  itself  to  such 
narrow  and  circumscribed  limits.  But,  whether  the  destruction 
of  the  intermediate  membrane  of  the  affected  parts  results  as  a 
consequence  of  actual  disease,  or  merely  from  vicious  nutrition ; 
or  whether  from  unknown  causes  it  has  failed  to  be  developed 
here,  it  is  certain  that  the  fibres  of  this  portion  of  the  enamel  are 
not  united  to  the  subjacent  dentine;  thus,  not  receiving  a  supply 
of  nutrient  fluid  or  vital  principle,  their  animal  frame-work  par- 
tially or  wholly  perishes,  leaving  but  little  else  than  their  inor- 
ganic constituents.  The  cause  of  this  variety  of  congenital 
atrophy,  it  must  be  confessed,  is  very  obscure ;  and  in  the  ab- 
sence of  positive  knowledge,  we  can  only  infer  the  cause  from 
the  nature  of  the  affection.  If  it  does  not  result  from  one  or 
other  of  the  above-mentioned  causes,  it  is  difficult  to  imagine  in 
what  way  it  is  produced. 

The  cause  of  the  second  variety  of  odontatrophia  is,  we  think, 
susceptible  of  a  more  satisfactory  explanation.  The  formative 
organ  of  the  enamel,  as  is  now  generally  admitted,  consists  of  a 
membrane,  composed  almost  wholly  of  short  hexagonal  corpuscles 
or  fibres,  which  correspond  in  shape  and  arrangement  to  the 
fibres  of  the  enamel.  This  membrane  is  accurately  moukled  to 
the  crown  of  the  tooth,  and,  according  to  Raschkow,  each  fibre 
is  a  secretory  duct,  whose  peculiar  function  it  is  to  secrete  the 
fibre  of  the  enamel  corresponding  to  it.  It  should  also  be  borne 
in  mind  that  the  secretion  of  the  earthy  salts  of  the  enamel  com- 
mences at  the  coronal  extremity  of  the  tooth,  gradually  proceed- 
ing toward  the  base  of  the  crown.  Now  we  can  readily  conceive 
that  some  constitutional  disease  might  interrupt  the  secretion  of 
the  earthy  salts  deposited  in  the  enamel-cells  or  secretory  ducts 
of  the  enamel  membrane,  for  the  formation  of  the  enamel  fibres  ; 
occurring  at  the  time  when  this  process  is  going  on,  it  might 
prevent  them  from  being  filled,  and  cause  them  to  wither  or  waste 
away,  giving  to  this  portion  of  the  enamel  the  pitted  appearance 
which  characterizes  this  variety  of  atrophy.  In  other  words, 
the  secretion  of  the  inorganic  constituents  of  the  enamel  being  in- 
26 


394         CAUSES  OF  ATROPHY  OF  THE  TEETH. 

terrupted  for  a  short  time  the  horizontal  row  of  cells  in  the  enamel 
membrane,  into  which  it  should  be  deposited,  will  not  be  filled; 
consequently,  as  might  readily  be  supposed,  they  will  waste 
awav,  leaving  a  circular  row  of  indentations  around  the  crown 
of  the  tooth.  But  as  soon  as  the  constitutional  disease  has  run 
its  course,  the  secretion  of  the  earthy  salts  will  be  resumed ;  and 
unless  the  child  experiences  a  relapse,  or  has  a  second  attack  of 
disease,  capable  of  interrupting  this  secretory  process,  the  other 
parts  of  the  enamel  will  be  well  formed. 

Some  writers  ascribe  the  formation  of  these  pits  in  the  enamel 
to  the  chemical  action  of  a  corrosive  fluid,  or  to  an  acidulated 
condition  of  the  fluid  contained  in  the  dental  sacs;  but  they  have 
evidently  confounded  this  affection  with  erosion.  We  believe, 
however,  it  almost  always  occurs  as  a  consequence  of  some  erup- 
tive disease  or  catarrhal  fever  occurring  during  the  "  enameling" 
process;  and  there  are  many  facts  which  go  to  sustain  the  cor- 
rectness of  this  opinion.  In  nearly  all  the  cases  that  have  fallen 
under  our  observation,  it  was  clearly  traceable  to  measles,  scar- 
latina, chicken-pox,  catarrhal  fever,  or  small-pox.  It  may,  how- 
ever, occasionally  be  produced  by  other  constitutional  diseases. 
,  The  third  variety  of  dental  atrophy,  so  far  as  our  observation 
upon  the  subject  has  permitted  us  to  form  an  opinion,  always 
results  from  altered  or  vicious  nutrition,  caused  by  disease  of  the 
jiulp  or  enamel  membrane,  or  both,  during  the  secretion  of  the 
dentine  or  enamel,  accordingly  as  one  or  both  are  affected.  We 
are  inclined  to  believe  that  the  disease  in  the  dental  pulp  or 
enamel  membrane  may  be  produced  either  by  local  or  constitu- 
tional causes,  or  both.  But  the  information  which  we  have  been 
able  to  obtain  in  the  cases  that  we  have  seen,  concerning  the 
state  of  the  general  health,  and  that  of  the  mouth  at  the  time 
of  the  dentinification  of  the  pulp  and  the  secretion  of  the 
enamel,  has  not  been  as  satisfactory  as  we  could  have  wished. 

Since  writing  the  foregoing,  the  following  interesting  case  of 
dental  atrophy  has  fallen  under  our  observation : 

Mrs.  C.  called,  in  1850,  to  consult  us  concerning  her  daugh- 
ter's teeth,  which,  from  congenital  defect,  presented  a  most  un- 
sightly appearance.  The  girl  was  between  nine  and  ten  years 
of  age.  The  cutting  edges  of  the  upper  central  incisors  were 
badly  pitted  and  very  rough;  the  corresponding  teeth  in  the 


TREATMENT  OF  ATROPHY  OF  THE  TEETH.        395 

lower  jaw  had  a  transverse  row  of  pits  passing  around  them, 
about  a  sixteenth  of  an  inch  below  their  cutting  extremities. 
Another  row  of  pits,  so  close  together  as  to  form  a  rough  groove, 
encircled  the  upper  central  incisors,  about  an  eighth  of  an  inch 
below  the  gum,  and  the  laterals  a  little  nearer  their  cutting 
edges ;  the  lower  incisors  were  similarly  marked,  but  not  quite 
so  near  the  gum.  The  enamel,  near  the  second  transverse  row 
of  pits,  and  between  it  and  the  cutting  edges  of  the  teeth,  was 
thin  and  of  a  light  brown  color.  A  little  above  the  first  row,  on 
the  central  incisors,  were  two  or  three  brown  "or  opaque  spots. 
The  first  permanent  molars  were  also  encircled  with  a  row  of  in- 
dentations, about  half  way  between  their  grinding  surfaces  and 
the  gums. 

On  inquiry,  we  learned  from  the  mother  that  the  child  had  a 
light  attack  of  measles  when  between  eleven  and  twelve  months 
old;  of  scarlet  fever  when  about  fifteen  or  sixteen  months  of 
age,  and  dysentery  at  about  the  twenty-first  or  twenty -second 
month. 

Now,  here  we  have  the  three  varieties  of  atrophy  on  the  same 
teeth;  and  the  occurrence  of  constitutional  diseases  about  the 
time  when  the  affected  parts  of  the  teeth  must  have  been  re- 
ceiving their  earthy  salts,  would  seem  to  establish,  very  conclu- 
sively, the  connection  of  the  one  with  the  other. 

TREATMENT. 

The  nature  of  this  affection  is  such  as  not  to  admit  of  cure. 
The  treatment,  therefore,  must  be  preventive  rather  than  cura- 
tive. All  that  can  be  done  is  to  mitigate  the  severity  of  such 
diseases  as  are  supposed  to  produce  it,  by  the  administration  of 
proper  remedies.  By  this  means  their  injurious  effect  upon  the 
teeth  may,  perhaps,  be  partially  or  wholly  counteracted. 

It  seldom  happens  that  atrophied  teeth  decay  more  readily 
than  others,  so  that  the  only  evil  resulting  from  the  affection,  is 
a  disfiguration  of  the  organs.  When  the  cutting  edges  of  the 
incisors  only  are  affected,  the  diseased  part  may  sometimes  be 
removed  with  a  file  without  injury  to  the  teeth. 


CHAPTER    THIRTEENTH. 
NECROSIS  OF  THE  TEETH. 

By  the  term  necrosis^  when  applied  to  a  tooth,  is  meant  the 
death  of  the  entire  organ  ;  or  of  the  crown  and  inner  walls  of 
the  root  ;'for  it  often  happens  that  a  degree  of  vitality  is  kept  up 
in  the  outer  portion  of  the  dentine  and  the  investing  cementum 
by  the  peridental  membrane,  long  after  the  destruction  of  the 
pulp  and  lining  membrane.  When  other  bones  are  affected  with 
necrosis,  the  dead  part  is  thrown  off,  and  the  loss  supplied  by 
the  formation  of  new  bone.  But  the  teeth  are  not  endowed  with 
the  recuperative  power  wliich  the  process  of  exfoliation  calls  for. 

The  density  of  a  tooth  is  not  sensibly,  if  at  all,  affected  by 
the  mere  loss  of  vitality  ;  but  so  great  a  change  takes  place  in 
the  appearance  of  the  organ,  that  it  may  readily  be  detected  by 
the  most  careless  observer.  After  the  destruction  of  the  lining 
membrane,  the  tooth  gradually  loses  its  peculiar  semi-translucent 
and  animated  appearance,  assuming  a  dingy  or  muddy  brown 
color ;  and  this  change  is  more  striking  in  teeth  of  a  s.oft  than 
in  those  of  a  hard  texture.  The  discoloration,  too,  is  always 
more  marked  when  the  loss  of  vitality  has  resulted  from  a  blow, 
than  when  produced  in  a  more  gradual  manner.  The  discolora- 
tion is  partly  owing  to  the  presence  of  disorganized  matter  in 
the  pulp-cavity,  and  partly  to  the  absorption  of  this  matter  by 
the  surrounding  walls  of  dentine. 

After  the  destruction  of  the  lining  membrane,  the  tooth  may 
receive  a  sufficient  amount  of  vitality  from  the  alveolo-dental 
periosteum  to  prevent  it  from  exerting  a  manifest  morbid  influ- 
ence upon  the  parts  with  which  it  is  immediately  connected. 
Teeth  have  occasionally  been  retained  under  such  circumstances 
with  apparent  impunity  for  fifteen  or  twenty  years.  But  when 
every  part  of  a  tooth  has  lost  its  vitality,  it  becomes  an  extrane- 
ous body.  When  this  happens,  inflammation  of  the  socket 
ensues,  the  gum  around  it  becomes  turgid  and  spongy,  and 
bleeds  from  the  slightest  injury,  and  the  organ  gradually  loosens 
and  ultimately  drops  out.    In  the  mean  time,  the  diseased  action 


TREATMENT  OF  NECROSIS  OF  THE  TEETH.        397 

frequently  extends  to  the  sockets   and  gums  of  the  adjoining 
teeth. 

The  front  teeth,  being  more  exposed  to  injuries  from  violence, 
are  more  liable  to  necrosis  than  the  molars. 

CAUSES. 

Necrosis  of  the  teeth  may  be  produced  by  a  variety  of  causes, 
such  as  protracted  fevers,  the  long  continued  use  of  mercurial 
medicines;  by  caries,  and  by  external  violence.  The  immediate 
cause,  however,  when  not  occasioned  by  a  blow  sufficient  to  de- 
stroy the  vascular  connection  of  the  tooth  with  the  rest  of  the 
system,  is  inflammation  and  suppuration  of  the  lining  membrane ; 
but  it  may  result  from  deficiency  of  vital  energy  and  from  impair- 
ed nutrition ;  for  the  author  has  met  with  several  cases  in  which 
the  loss  of  vitality  could  not  be  accounted  for  in  any  other  way. 

TREATMENT. 

When  a  tooth,  deprived  of  vitality,  is  productive  of  injury  to 
the  gums  and  to  the  adjacent  teeth,  it  should  be  immediately 
removed ;  for,  however  important  or  valuable  it  may  be,  the 
health  and  durability  of  the  others  should  not  be  jeopardized  by 
its  retention. 

When  necrosis  of  a  tooth  is  apprehended,  we  should  endeavor 
to  prevent  its  occurrence,  by  the  application  of  leeches  to  the 
gums,  and  by  gargling  the  mouth  with  suitable  astringent  washes. 
If  this  plan  of  treatment  is  adopted  at  an  early  period,  it  will 
sometimes  prevent  the  loss  of  vitality ;  but  if  long  neglected,  a 
favorable  result  need  not  be  anticipated. 

'  When  the  loss  of  vitality  is  confined  to  the  crown  and  inner 
walls  of  the  root,  if  the  former  is  not  seriously  impaired  by  caries, 
it  may  be  perforated,  and  the  pulp-cavity  and  root  cleansed  and 
filled  in  the  manner  as  directed  in  another  part  of  this  work. 
If  the  necrosed  tooth  is  an  incisor,  the  perforation  should  be 
made  from  the  palatine  surface,  provided  the  approximal  surfaces 
are  sound.  But  previously  to  the  introduction  of  a  filling,  the 
decomposed  surface  of  the  walls  of  the  pulp-cavity  should  be 
completely  removed,  and  if  this  does  not  restore  the  tooth  to  its 
natural  color,  the  cavity  should  be  filled  with  raw  cotton,  satu- 
rated with  a  solution  of  chlorinated  soda,  as  directed  in  another 
chapter. 


CHAPTER     FOURTEENTH. 
EXOSTOSIS  OF  THE  ROOTS  OF  THE  TEETH. 


This  disease  is  common  to  all  bones,  but  it  attacks  no  other 
part  of  a  fully  formed  tooth  than  the  root ;  for  in  the  cementum 
alone,  of  the  three  osseous  dental  tissues,  do  we  find  that  degree 
of  vascularity  which  is  a  necessary  condition  of  growth, — normal 
or  abnormal.  It  usually  commences  at  or  near  the  extremity, 
then  extends  upward,  covering  a  greater  or  less  portion  of  the 
external  surface.  It  sometimes,  however,  commences  upon  the 
side  of  the  root  and  forms  a  large  tubercle  ;  at  other  times  the 
deposit  of  the  new  bony  matter  is  spread  over  its  surface,  often 
uniformly,  but  more  frequently  unequally.  The  osseous  matter 
thus  deposited,  has  usually  the  color,  consistence  and  structure 
of  the  cementum,  though  sometimes  it  is  a  little  harder  and  as- 
sumes a  yellower  tinge.  The  enlargement  is  in  fact  an  hyper- 
trophied  condition  of  this  substance.  Those  singular  anomalies, 
occasionally  met  with,  where  enamel,  dentine,  and  cementum  are 
mixed  up  in  shapeless  confusion,  are  no  exceptions  to  the  rule 
that  exostosis  is  confined  to  the  cementum ;  for  though  classed 
under  this  head,  these  cases  arise  from  disruption  of  the  forma- 
tive membranes,  (possibly  the  result  of  violence,)  each  secreting 

its  peculiar  tissue.  The  hyper- 
trophy is  probably  confined  to 
the  dentine ;  yet  it  is  quite 
possible  for  the  dentinal  and 
enamel  membranes  in  their 
then  vascular  condition  to  have 
an  excess  of  development. 

The  deposit  of  osseous  mat- 
ter is  sometimes  so  consider- 
able, that  the  roots  of  two  or 
more  teeth  are  firmly  united 
by  it.  Fig.  152,  represents 
several  examples  of  exodonto- 
One  of  these  was  presented  to  him  by 


Fig.   152. 


sis  of  this  description. 


EXOSTOSIS    OF   THE    ROOTS    OF    THE    TEETH.  399 

Drs.  Blandin  and  Reynolds,  of  Columbia,  South  Carolina. 
These  with  many  other  remarkable  cases,  including  one  pre- 
sented by  Dr.  Hawes,  in  which  three  teeth  are  thus  united,  may 
be  seen  in  the  Museum  of  the  Baltimore  College  of  Dental 
Surgery. 

An  extraordinary  case  of  dental  exostosis  was  sent  to  the 
author  for  examination,  by  Dr.  V.  M.  Swayze,  of  Easton,  Pa, 
The  tooth  apparently  is  a  dens  sapientise,  and  the  formation  of 
the  exostosis  must  have  commenced  with  the  dentinification  of 
the  pulp.  It  had  spread  over  every  part  of  the  tooth,  the  crown 
as  well  as  the  root ;  it  had  ruptured  and  penetrated  every  part 
of  the  enamel  membrane,  but  had  not  wholly  destroyed  the  func- 
tion of  this  organ,  as  nodules  of  enamel  are  seen  in  various  parts 
of  the  exostosis.  The  tumor,  including  the  tooth,  is  about  as 
large  as  a  common  sized  hickory  nut. 

Exodontosis  often  continues  for  a  long  time  without  producing 
any  inconvenience  whatever.  It  usually  first  manifests  itself  by 
slight  soreness  in  the  affected  tooth,  which  increases  as  the  fang 
becomes  enlarged,  until  pain,  either  constant  or  periodical,  and 
of  a  character  more  or  less  severe,  is  experienced. 

The  most  remarkable  case  of  exodontosis  on  record,  is  related 
by  Mr.  Fox.  The  subject  was  a  young  lady,  who,  at  the  time 
she  came  to  Mr.  F.,  had  suffered  so  much  and  so  long,  that  the 
palpebrse  of  one  eye  had  been  closed  for  near  two  months ;  and 
the  secretion  of  saliva  had,  for  some  time,  been  so  copious,  that 
it  flowed  from  her  mouth,  whenever  opened.  She  had  tried  every 
remedy  science  and  skill  could  suggest,  without  experiencing 
any  permanent  benefit,  and  was  only  relieved  from  her  suffering 
by  the  extraction  of  every  one  of  her  teeth. 

In  the  course  of  the  author's  practice,  he  has  removed  many 
teeth  affected  with  exostosis,  but  has  never  met  with  a  case  simi- 
lar to  that  described  by  Mr.  F.  In  one  instance,  he  was  com- 
pelled to  extract  four  sound  teeth  and  nine  roots ;  yet  the  pain 
was  not  at  any  time  severe,  but  it  was  constant,  and  a  source  of 
great  annoyance  to  the  patient.  The  following  is  one  among  the 
many  cases  which  have  fallen  under  his  observation  : 

Mr.  S.,  of  Baltimore,  in  the  fall  of  1845,  called  upon  us  for 
advice.  Having  for  some  time  suffered  pain  in  the  first  left 
superior  bicuspid,  he  had  applied  two  years  before  to  a  dentist, 

V 


400  EXOSTOSIS    OF   THE    ROOTS    OF   THE   TEETH. 

for  the  purpose  of  having  the  tooth  removed.  In  the  operation, 
the  root,  about  three-sixteenths  of  an  inch  from  its  extremity, 
was  fractured  and  left  in  the  socket.  In  consequence  of  this, 
the  gnawing  pain  with  which  he  had  for  a  long  time  before  been 
troubled,  continued,  and  at  the  expiration  of  twelve  months,  the 
gum  over  the  remaining  portion  of  the  root  became  very  much 
swollen,  puflSng  out  the  lip  to  the  size  of  half  a  hen's  egg.  The 
tumor,  after  a  few  days,  was  opened,  and  a  large  quantity  of 
dark-colored,  fetid,  purulent  matter  was  discharged,  which,  for  a 
short  time,  gave  considerable  relief.  The  tumor,  hoAvever,  was 
re-formed  and  opened  some  four  or  five  times  in  as  many  months. 
At  this  time  his  gum  was  swollen,  and  the  upper  lip  puffed  out 
in  the  manner  just  described.  On  opening  the  tumor,  about 
three  table-spoonfuls  of  black  matter,  resembling  thin  tar,  es- 
caped. We  then  found,  upon  examination,  that  the  outer  wall 
of  the  antrum,  immediately  over  the  remaining  portion  of  the 
root  of  the  first  bicuspid,  was  destroyed,  and  there  was  an  open- 
ing through  it  large  enough  to  admit  the  fore-finger.  Believing 
that  the  extremity  of  the  root  left  in  the  socket  was  the  cause  of 
the  disease,  we  immediately  proceeded  to  extract  it,  which  we 
succeeded  in  doing  after  removing  the  outer  wall  of  the  alveolus. 
The  root  was  found,  on  removal,  to  be  enlarged  by  exostosis  to 
the  size  of  a  very  large  pea.  The  operation  proved  perfectly 
successful,  the  secretion  of  purulent  matter  soon  ceased,  and  in 
a  few  weeks  he  was  completely  relieved  from  the  troublesome 
affection  under  which  he  had  so  long  labored. 

CAUSES. 

The  primary  cause  of  this  disease  does  not  appear  to  be  well 
understood.  Most  writers  concur  in  attributing  the  proximate 
cause  to  irritation  of  the  periosteum  of  the  fang ;  but  this  is  not, 
as  some  suppose,  necessarily  dependent  upon  any  morbid  condi- 
tion of  the  crown  itself,  for  it  often  attacks  teeth  that  are  per- 
fectly sound.  It  seems  rather  to  be  attributable  to  some  pecu- 
liar constitutional  diathesis. 


EXOSTOSIS    OF    THE    ROOTS    OF    THE    TEETH.  401 


TREATMENT. 

The  disease  having  established  itself  does  not  admit  of  cure, 
and  when  it  has  progressed  so  far  as  to  be  productive  of  pain 
and  inconvenience  to  the  patient,  the  loss  of  the  affected  teeth 
becomes  inevitable.  When  the  enlargement  is  very  considerable 
and  confined  to  the  extremity  of  the  root,  and  has  not  induced  a 
corresponding  enlargement  of  the  alveolus  around  the  neck  of 
the  tooth,  the  extraction  of  the  affected  organ  is  often  attended 
■with  difficulty,  and  can  only  be  accomplished  by  removing  a  por- 
tion of  the  socket,  or  fracturing  it. 


CHAPTER     FIFTEENTH. 
SPINA  VENTOSA  OF  THE  TEETH. 

Among  the  diseases  which  attack  the  teeth,  Mr.  Fox  mentions 
spina  ventosa,  but  the  author  thinks  that  the  name  is  not  strictly 
applicable  to  the  affection  of  which  he  treats  under  that  designa- 
tion. This  term  in  surgery  is  applied  to  an  expansion  of  bone 
from  a  collection,  in  the  broken  down  cancellated  structure,  of  a 
fluid,  generally  purulent,  sometimes  dark-colored.  It  is  caused 
by  injury,  or  proceeds  from  cachexia  and  constitutional  debility. 
It  differs  from  osteosarcoma  in  not  being  malignant,  also  in  not 
throwing  out  any  fungous  growth  when  the  outer  walls  of  bone 
give  way. 

Mr.  Fox  describes  the  disease  as  being  seated  in  the  cavity  of 
the  tooth  ;  "the  vessels  ramifying  on  its  membrane  acquire  a  dis- 
eased action  by  which  the  membrane  becomes  thickened,  absorp- 
tion of  some  of  the  internal  parts  of  the  tooth  takes  place,  and 
the  opening  at  the  extremity  of  the  fang  becomes  enlarged.  This 
disease  of  the  membrane  is  attended  with  the  formation  of  mat- 
ter, discharging  itself  at  the  point  of  the  fang,  into  the  alveolar 
cavity,  which,  being  rendered  more  porous  by  the  process  of  ab- 
sorption, affords  an  easy  exit.  During  the  progress  of  the 
disease,  the  gum  covering  the  alveolar  process  becomes  inflamed, 
and  acquires  a  spongy  texture  ;  the  matter,  passing  from  the 
socket,  makes  its  escape  into  the  mouth  by  several  openings 
through  the  gum,  which  is  thus  kept  in  a  constant  state  of  dis- 
ease." 

Now,  it  will  be  perceived,  that  there  is  little  or  no  analogy  be- 
tween spina  ventosa  and  the  disease  spoken  of  by  Mr.  Fox  ; 
which  is  nothing  more  than  the  result  of  alveolar  abscess,  arising 
from  inflammation  and  suppuration  of  the  lining  membrane. 
When  matter  is  confined  in  the  cavity  of  the  tooth,  the  canal  in 
the  root  may  become  greatly  enlarged.     The  author  has  met 


TREATMENT    OF    SPINA    VENTOSA.  •    403 

with  many  cases  where  this  has  happened,  and  lie   has  in   his 
possession  several  specimens  of  teeth  thus  affected. 

If,  previously  to  the  suppuration  of  the  lining  membrane  and 
pulp,  the  tooth  should  be  affected  with  exostosis,  the  disease 
would  then  bear  some  resemblance  to  spina  ventosa,  which  is 
characterized  by  external  enlargement  of  the  bone ;  whereas,  in 
the  disease  in  question,  the  size  of  the  root  is  seldom  increased. 
The  external  appearance  of  the  organ  is  that  of  a  necrosed  tooth. 

CAUSES. 

The  enlargement  of  the  opening  at  the  extremity  of  the  root, 
is  not,  as  Mr.  Fox  believes,  caused  by  the  action  of  the  absor- 
bents ;  since  before  this  takes  place,  the  lining  membrane  has 
been  destroyed,  and  the  vital  powers  of  the  root  are  so  much  re- 
duced as  to  preclude  the  possibility,  even  admitting  that  the  ab- 
sorbents are  capable  of  effecting  such  enlargement,  of  its  being 
accomplished  through  their  agency.  The  enlargement  is  wholly 
attributable  to  the  action  of  the  corrosive  matter  contained  in  the 
root.  This  explanation  appears  the  more  probable  when  we  con- 
sider that  the  matter  discharged  from  the  socket,  is  ichorous, 
offensive,  and  of  an  irritating  character. 

TREATMENT. 

A  tooth  affected  with  this  disease  does  not  admit  of  cure. 
The  proper  treatment,  therefore,  consists  in  its  prompt  removal. 
There  are  no  local  nor  general  remedies  which  can  be  applied, 
capable  of  affording  relief.  The  symptoms,  perhaps,  may  some- 
times be  palliated ;  but  it  is  not  advisable  to  tamper  with  a  tooth 
thus  affected,  as  it  will  only  serve  to  protract  and  ultimately  to 
augment  the  evil. 

It  is  possible  that  the  occurrence  of  the  affection  might,  in 
some  cases,  be  prevented  by  prompt  antiphlogistic  treatment  ; 
such  as  is  recommended  for  the  prevention  of  necrosis,  and  for 
the  cure  of  tooth-ache  caused  by  inflammation  of  the  lining  mem- 
brane. But  after  suppuration  has  taken  place,  and  a  secretion 
of  fetid  and  corrosive  matter  has  been  kept  up  until  the  canal  of 
the  root  has  become  enlarged,  the  proper  remedial  indication  is 
the  removal  of  the  tooth. 


CHAPTER     SIXTEENTH. 

DENUDING  OF  THE  TEETH. 

This  is  one  of  the  most  remarkable  aflfections  to  which  the 
teeth  are  liable.  It  consists  in  the  gradual  wasting  of  the  enamel 
on  the  labial  surfaces,  attacking  first  the  central  incisors,  then 
the  laterals,  afterwards  the  cuspids  and  bicuspids,  extending 
sometimes  to  the  first  and  second  molars.  It  usually  forms  a 
continuous  horizontal  groove,  as  regularly  and  smoothly  con- 
structed as  if  it  had  been  made  with  a  file.   See  Fig.  153.  After 

Fig.  153.  Fig.  154. 


it  has  removed  the  enamel,  it  commits  its  ravages  upon  the  sub- 
jacent dentine,  sometimes  penetrating  to  the  pulp-cavity.  It 
rarely  changes  the  color  of  the  enamel,  but  the  dentine,  after  it 
becomes  exposed,  assumes  first  a  light,  and  afterwards  a  dark- 
brown  color ;  retaining,  however,  a  smooth  and  polished  surface. 
This  destructive  process  does  not  always  commence  at  merely 
one  point  on  the  labial  surface  of  the  central  incisors,  as  just  de- 
scribed ;  it  sometimes  attacks  several  points  simultaneously.  (See 
Fig.  154.)  As  it  spreads,  these  unite,  and  ultimately  a  deep 
excavation  is  formed,  with  walls  so  smooth  and  highly  polished 
that  the  tooth  presents  the  appearance  of  having  been  scooped 
out  with  a  broad,  square,  or  round-pointed  instrument. 

The  progress  of  the  affection  is  exceedingly  variable.  It  is 
sometimes  so  rapid  that  the  dentine  becomes  exposed  within  two 
or  three  years  from  the  commencement  of  the  disease  ;  at  other 
times  its  effect  upon  the  enamel  is  scarcely  perceptible  for  the 
first  six  or  eight  years  after  it  makes  its  appearance.  In  the 
case  of  a  lady  whose  teeth  were  thus  affected,  the  denuding  pro- 
cess did  not  perforate  the  enamel  for  nearly  twenty  years.     The 


CAUSES    OF    DENUDING    OF    THE    TEETH.  405 

dentine,  after  it  is  denuded  of  enamel,  is  generally  quite  sensi- 
tive, and  very  susceptible  to  heat  and  cold. 


CAUSES. 

The  cause  of  this  singular  affection  has  never  been  satisfac- 
torily explained.  It  was  first  noticed  by  Mr.  Hunter,  who  calls 
it  decay  by  denudation,  and  supposes,  that  it  is  a  disease  inhe- 
rent in  the  tooth  itself,  and  not  dependent  on  circumstances  in 
after  life:  for  the  reason  that  it  attacks  certain  teeth  rather 
than  others,  and  is  often  confined  to  a  particular  tooth. 

]\Ir,  Boll  thinks  Mr.  Hunter  has  confounded  this  affection  with 
another,  similar  in  its  appearance,  but  arising  from  a  wholly  dif- 
ferent cause.  Mr.  Hunter  states  that  he  has  seen  instances 
where  it  appeared  as  if  the  outer  surface  of  the  dentine,  which 
is  in  contact  with  the  inner  surface  of  the  enamel,  had  first  been 
lost,  so  that  the  cohesion  between  the  two  had  been  destroyed ; 
and  as  if  the  enamel  had  been  separated  for  want  of  support, 
for  it  terminates  abruptly.  Upon  which  Mr.  Bell  remarks: 
"Mr.  Hunter  describes  very  accurately  the  result  of  superficial 
absorption  of  the  bony  structure;  a  circumstance  which  I  have 
occasionally  seen,  though  more  rarely  than  the  present  abrasion 
of  the  enamel,  with  which  it  cannot  for  a  moment  be  considered 
as  identical.  In  one  case  the  enamel  is  gradually  and  slowly 
removed  by  a  regular  and  uniform  excavation ;  in  the  other,  the 
abruptness  and  irregularity  of  the  edges  show  that  it  had  broken 
away  at  once,  from  having  lost  its  subjacent  support.  The  cause 
of  the  former  is  external;  in  the  latter  it  is  within  the  enamel." 

Mr.  Bell,  in  attempting  to  correct  one  error,  has  fallen  into 
another,  equally  great  and  palpable.  He  attributes  the  break- 
ing in  of  the  enamel  to  absorption  of  the  subjacent  dentine,  in- 
stead of  ascribing  it  to  decomposition  by  chemical  agents,  which 
is  the  true  cause.  In  almost  every  instance,  where  the  author 
has  found  the  edges  of  the  enamel  in  the  condition  described 
by  Messrs.  Hunter  and  Bell,  he  has  also  observed  that  the  sur- 
face of  the  exposed  dentine  was  decayed.  But  the  breaking  in 
of  the  enamel  is  not  the  affection  now  under  consideration.  That 
is  the  result  of  caries  of  the  subjacent  dentine;  this,  a  sort  of 
spontaneous  abrasion. 


406  CAUSES    OF    DENUDING    OF   THE   TEETH. 

Mr.  Bell  is  unfortunate,  also,  in  the  suggestions  which  he 
throws  out  in  regard  to  the  cause  of  the  disease.  "  Whatever  may 
be  the  cause, — and  at  present  I  confess  myself  at  a  loss  to  ex- 
plain it. — the  horizontal  direction  in  which  it  proceeds  may,  I 
think,  be  connected  with  the  manner  in  which  the  enamel  is  de- 
posited during  its  formation ;  for  it  will  be  recollected  that  it 
first  covers  the  apex  of  the  tooth,  and  gradually  invests  the 
crown  by  successive  circular  depositions ;  it  is,  therefore,  not  im- 
probable that,  from  some  temporary  cause,  acting  during  its  de- 
position, certain  circular  portions  may  be  more  liable  to  me- 
chanical abrasion,  or  other  injury  than  the  rest." 

This  conjecture,  though  it  may  seem  somewhat  plausible,  is 
far  from  satisfactory.  If,  as  he  supposes,  certain  circular  por- 
tions of  the  enamel  are  less  perfectly  formed  than  others,  and 
consequently  rendered  more  liable  to  the  disease,  it  would  not 
be  wholly  confined  to  the  anterior  surface  of  the  tooth ;  but 
would  extend  entirely  around  it,  and  as  soon  as  these  imperfectly 
formed  circular  portions  Avere  destroyed,  its  ravages  would  cease. 

Mr.  Fox  frankly  acknowledges  his  inability  to  assign  any 
cause  for  this  aflection ;  but  conjectures  that  it  is  dependent 
upon  some  solvent  quality  of  the  saliva.  Were  this  supposi- 
tion correct,  every  part  of  the  tooth  would  be  alike  subject  to 
its  attack. 

Other  writers  suppose  it  is  occasioned  by  the  friction  of  the 
lips.  But  this  hypothesis  is  destitute  of  the  least  semblance  of 
plausibility;  for  the  narrowness  and  depth  of  the  grooves  are 
sometimes  such  as  to  preclude  the  possibility  of  the  contact  of 
the  lips  with  their  surfaces. 

Some  eminent  practitioners,  again,  attribute  it  to  the  use  of 
tooth-brushes.  That  this  may  increase  the  size  of  the  horizontal 
groove  is  more  than  probable;  that  it  may  even  in  some  cases  de- 
termine the  commencement  of  the  groove,  is  just  possible.  But 
no  conceivable  action  of  the  brush  could  be  an  incitino-  cause  of 
that  form  of  the  disease  shown  in  Fig.  154.  The  true  explana- 
tion must  meet  both  cases.  Hence  the  author  has  been  led  to 
adopt  the  opinion  that  the  loss  of  substance  which  characterizes 
the  affection  is  produced  by  the  action  of  acidulated  buccal 
mucus.  In  every  other  part  of  the  mouth  this  fluid  is  mixed 
with  !«aliva,  and  the  acid  it  contains  so  much  diluted  as  to  pre- 


TREATMENT    OF    DENUDED    TEETH.  407 

vent  it  from  acting  on  other  portions  of  the  teeth.  Dr.  E. 
Parmly  reports  a  case,  in  which  the  natural  teeth,  set  upon  an 
artificial  piece,  were  attacked  in  the  same  manner. 


TREATMENT. 

As  a  preventive,  Mr.  Fox  recommends  the  avoidance  of  what- 
ever tends  to  produce  it,  but  unfortunately  he  leaves  his  readers 
entirely  in  the  dark  upon  this  subject.  In  advanced  stages  of 
the  affection,  the  author  has  often  succeeded  in  arresting  its  pro- 
gress by  widening  the  groove  at  the  bottom,  and  afterwards  filling 
it  with  gold.  This,  in  the  majority  of  cases,  will  prove  success- 
ful. The  patient  should  be  cautioned  against  the  use  of  stiff- 
bristled  tooth-brushes  ;  and  should  not,  in  using  any  kind,  make 
too  much  movement  across  the  front  teeth,  but  rather  up  and 
down.  Should  the  groove  become  discolored,  it  will  be  proper 
to  use  occasionally  a  little  fine  rotten-stone  or  prepared  chalk  on 
a  small  stick  of  some  hard  wood. 


CHAPTER    SEYEXTEENTH. 

SPONTANEOUS  ABRASION  OF  THE  CUTTING  EDGES  OF 
THE  FRONT  TEETH. 

The  spontaneous  abrasion  of  the  cutting  edges  of  the  front 
teeth  is  an  affection  of  very  rare  occurrence.  It  commences  on 
the  central  incisors ;  proceeding  thence  to  the  laterals,  the 
cuspids,  and  sometimes,  though  very  rarely,  to  the  first  bicus- 
pids. Teeth  thus  affected  have,  when  the  jaws  are  closed,  a 
truncated  appearance;  the  upper  and  lower  teeth  do  not  come 
together,  and  they  are  rather  more  than  ordinarily  susceptible 
to  the  action  of  acids,  or  of  heat  and  cold.  In  other  respects, 
little  or  no  inconvenience  is  experienced  until  the  crowns  of  the 
affected  teeth  are  nearly  destroyed. 

Its  progress,  as  in  the  case  of  abrasion  of  the  labial  surfaces, 
is  exceedingly  variable.  It  sometimes  destroys  half  or  two- 
thirds  of  the  crowns  of  the  central  incisors  in  two  or  three 
years ;  at  other  times  seven  or  eight  years  are  required  to  pro- 
duce the  same  effect.  In  one  case  which  came  under  our  own  ob- 
servation, the  abrasion  had  extended  to  the  bicuspids ;  and  the 
central  incisors  of  both  jaws  were  so  much  wasted,  that  on 
closing  the  mouth,  they  did  not  come  together  by  nearly  three- 
eighths  of  an  inch;  yet  two  years  only  had  elapsed  since  its 
commencement.  In  another  case,  where  it  had  been  going  on 
for  seven  years,  it  had  not  extended  to  the  cuspids,  and  the  space 
between  the  upper  and  lower  incisors  did  not  exceed  an  eighth 

of  an  inch.     The  subjects  of 
Fig.  ]55.  ,  , 

these  two  were  gentlemen — 

the  first  aged  about  twenty- 
eight,  and  the  other  twenty- 
one. 

Mr.  Bell  gives  an  interesting 

case  (Fig.  155)  of  a  gentleman 

whose  teeth  were  thus  affected  :   "About  fourteen  months  since 

(1831),  this  gentleman  perceived  that  the  edgesof  the  incisors,  both 

above  and  below,  had  become  slightly  worn  down,  and,  as  it  were, 


CAUSES  OF  ABRASION  OF  THE  EDGES  OF  THE  TEETH.  409 

truncated,  so  that  they  could  no  longer  be  placed  in  contact  with 
each  other.  This  continued  to  increase  and  extend  to  the  late- 
ral incisors,  and,  afterward,  successively,  to  the  cuspids  and 
bicuspids.  There  has  been  no  pain,  and  only  a  trifling  degree 
of  uneasiness,  on  taking  acids,  or  any  very  hot  or  cold  fluids, 
into  the  mouth.  When  I  first  saw  these  teeth,  they  had  exactly 
the  appearance  of  having  been  most  accurately  filed  down  at  the 
edges,  and  then  perfectly  and  beautifully  polished;  and  it  has 
now  extended  so  far,  that  when  the  mouth  is  closed,  the  anterior 
edges  of  the  incisors  of  the  upper  and  lower  jaws  are  nearly  a 
quarter  of  an  inch  asunder.  The  cavities  of  those  of  the  upper 
jaw  must  have  been  exposed,  but  for  a  very  curious  and  beautiful 
provision ;  they  have  become  gradually  filled  by  a  deposit  of 
new  bony  matter,  perfectly  solid  and  hard,  but  so  transparent 
that  nothing  but  examination  by  actual  contact  could  convince 
an  observer  that  they  were  actually  closed.  This  appearance  is 
exceedingly  remarkable,  and  exactly  resembles  the  transparent 
layers  which  are  seen  in  agatose  pebbles,  surrounded  by  a  more 
opaque  mass.  The  surface  is  uniform,  even,  and  highly  polished,' 
and  continues,  without  the  least  break,  from  one  tooth  to  an- 
other. It  extends  at  present  to  the  bicuspids,  is  perfectly  equal 
on  both  sides,  and  when  the  molars  are  closed,  the  opening,  by 
this  loss  of  substance  in  front,  is  observed  to  be  widest  in  the 
centre,  diminishing  gradually  and  equally  on  both  sides  to  the 
last  bicuspids." 

CAUSES. 
With  regard  to  the  cause  of  this  most  extraordinary  affection, 
Mr.  Bell,  referring  to  the  case  which  he  describes,  says,  he  is 
"wholly  at  a  loss  to  offer  even  a  conjecture.  It  cannot  have  been 
produced  by  the  friction  of  mastication,  for  these  teeth  have 
never  been  in  contact  since  the  commencement  of  the  affection ; 
nor  does  it  arise  from  any  apparent  mechanical  cause,  for  nothing 
is  employed  to  clean  the  teeth,  except  a  soft  brush.  Absorption 
will  equally  fail  to  account  for  it ;  for  not  only  would  this  cause 
operate,  as  it  always  does,  irregularly ;  but  we  find  that,  instead 
of  these  teeth  being  the  subjects  of  absorption,  a  new  deposition 
of  bony  matter  is,  in  fact,  going  on,  to  fill  the  pulp-cavities  which 
would  otherwise  be  exposed." 


410       TREATMENT  OF  ABRASION  OF  THE  TEETH. 

Mr.  Boll  is  correct  in  supposing  that  it  is  not  the  result  either 
of  mechanical  action  or  absorption.  If,  then,  neither  of  these 
agencies  are  concerned  in  its  production,  it  must  be  the  result  of 
some  chemical  action ;  though  not  of  the  salivary  fluids  of  the 
mouth,  for  if  so,  every  part  of  the  exterior  surfaces  of  the  teeth 
would  be  acted  on  alike.  This  affection,  as  well  as  the  one  last 
noticed,  the  author  is  disposed  to  attribute  to  the  action  of  acid- 
ulated mucus.  The  anterior  surfaces  of  the  upper  front  teeth 
not  being  so  frequently  washed  by  the  saliva,  the  mucous  secre- 
tions of  the  upper  lip  are  often  permitted  to  remain  on  these 
portions  of  the  teeth  for  a  considerable  length  of  time;  and  to 
the  presence  of  these,  when  in  an  acidulated  condition,  we  be- 
lieve the  denuding  process  to  be  attributable ;  while  the  abrasion 
of  the  cutting  edges  of  the  incisors  and  cuspids  is  caused  by  an 
acid  mucus,  secreted  from  the  mucous  follicles  of  the  end  of  the 
tongue,  which  is  brought  in  contact  with  the  cutting  extremities 
of  the  front  teeth  almost  constantly. 

Dr.  Nuhn,  a  German  physician,  describes  a  gland  which  he 
has  recently  discovered  in  the  interior  of  the  tip  of  the  tongue. 
It  is  represented  as  having  a  number  of  ducts  opening  through 
the  mucous  membrane  over  it.  It  is  thought  to  be  a  mucous 
gland,  and  it  may  be  that  this  gland,  in  peculiar  diatheses, 
secretes  the  acidulated  mucus  which  may  cause  the  affection 
under  consideration.  Be  this  hypothesis  correct  or  not,  it  is 
evidently  the  result  of  the  action  of  a  chemical  agent;  and  that 
this  is  furnished  by  the  end  of  the  tongue  is  rendered  more  than 
probable  from  the  fact,  that  it  is  brought  in  contact  with  the 
cutting  edges  of  the  teeth,  almost  every  time  the  mouth  is 
opened. 

TREATMENT, 

If  the  tendency  to  an  acidulated  condition  of  the  mucous 
secretions  of  the  mouth  could  be  overcome  or  counteracted,  the 
progress  of  this  affection  of  the  teeth,  perhaps,  might  be  arrested. 
But  the  permanent  cure  of  an  obscure  abnormal  condition  of 
any  secretion  is  a  tedious,  difficult  and  often  impossible  thing. 
It  may  require  hygienic  and  constitutional  treatment,  such  as 
eomes  more  within  the  province  of  the  family  physician  than  of 
the  dentist.  But  we  know  of  no  treatment  that  will  control  or 
arrest  this  singular  disease. 


CHAPTER    EIGHTEENTH. 
MECHANICAL  ABRASION  OF  THE  TEETH. 

Were  it  true,  as  declared  by  Riclierand,  that  the  loss  of  the 
enamel  occasioned  by  friction  is  repaired  by  a  new  growth,  it 
would  never  suffer  permanent  loss  from  mechanical  abrasion. 
But  enamel  and  dentine,  once  formed,  pass  beyond  the  sphere  of 
that  reparative  power  found  in  other  bony  tissues  where  red 
blood  circulates  freely.  New  enamel  is  therefore  never  formed 
after  the  eruption  of  the  tooth;  and  new  dentine  only  upon  the 
surface  of  the  lining  membrane,  which  is  exceedingly  vascular. 

The  teeth  rarely  suffer  loss  of  substance  from  friction  when 
the  incisors  of  the  upper  jaw  shut  in  front  of  those  of  the 
lower.  It  is  only  when  the  former  fall  directly  upon  the  latter, 
that  mechanical  abrasion  of  the  cutting  edges  can  take  place,  and 
when  this  happens,  they  sometimes  suffer  great  loss  of  substance. 
The  crowns  of  these  teeth  are  occasionally  worn  entirely  off, 
while  those  of  the  molars  and  bicuspids  are,  comparatively,  little 
affected.  The  lateral  motions  of  the  jaw,  being  in  these  cases 
unrestricted — and  this  motion  being  of  course  greater  at  the 
anterior  than  at  the  posterior  part  of  the  mouth — it  necessarily 
happens  that  the  front  teeth  suffer  the  most  abrasion.  Some- 
times all  the  teeth  are  worn  off  alike ;  at  other  times,  owing  to 
the  peculiar  manner  in  which  the  jaws  come  together,  the  abra- 
sion is  confined  to  a  few. 

Mr.  Bell  believes  that  certain  kinds  of  diet  tend,  more  than 
others,  to  produce  abrasion  of  teeth  :  in  proof  of  which  he  tells  us 
that  sailors,  who,  the  greater  portion  of  their  lives,  live  on  hard 
biscuits,  have  only  a  small  part  of  the  croAvns  of  their  teeth  re- 
maining. But  the  antagonism  of  the  teeth  has  much  more  to  do 
with  it  than  the  nature  of  the  food ;  though  of  course  when  they 
do  strike  in  such  a  way  as  to  wear  the  cutting  surfaces,  very  hard 
or  gritty  articles  of  food  would  make  the  abrasion  more  rapid. 

When  the  front  teeth  of  the  lower  jaw   strike   against  the 


412  MECHANICAL    ABRASION    OF    THE    TEETH. 

palatine  surface  of  those  of  the  upper,  the  latter  arc  sometimes 
worn  away  more  than  three-fourths,  and  in  some  instances  en- 
tirely up  to  the  gums.  We  have  seen  the  teeth  of  some  indi- 
viduals so  much  abraded,  in  this  way,  that  little  of  the  crown 
remained,  except  the  enamel  on  the  anterior  surface. 

The  wearing  away  of  the  crowns  of  the  teeth  would  expose 
the  lining  membrane ;  were  it  not  that  Nature,  in  anticipation  of 
the  event,  sets  up  an  action  by  which  the  pulps  are  transformed 
into  a  substance  called  o^teo-dentine,  which  is  analogous  in  struc- 
ture to  cementum.  By  this  beautiful  operation  of  the  economy, 
the  painful  consequences  that  would  otherwise  result  are  wholly 
prevented. 


CHAPTER    NINETEENTH. 

FRACTURES  AND  OTHER  INJURIES  OF  THE  TEETH 
FROM  MECHANICAL  VIOLENCE. 

The  injuries  to  which  teeth  are  subject  from  mechanical 
violence,  are  so  variable  in  their  character  and  results,  as  to 
render  a  detailed  description  impossible.  The  same  amount  of 
violence  inflicted  upon  a  tooth  does  not  always  produce  the  same 
eflFect.  The  nature  and  extent  of  the  injury  will  depend  as  much 
upon  the  physical  condition  of  the  teeth,  the  state  of  the  consti- 
tutional health,  and  the  susceptibility  of  the  body  to  morbid 
impressions,  as  upon  the  violence  of  the  blow.  Thus,  a  blow 
sufficiently  severe  to  loosen  a  tooth,  might  not,  in  one  case,  be 
productive  of  any  permanent  bad  consequences;  while  in  another, 
it  might  cause  the  death  of  the  organ  and  inflammation  of  the 
adjacent  parts,  as  well  as  necrosis  of  the  alveolus. 

A  tooth  of  compact  texture,  and  in  a  healthy  mouth,  may  be 
deprived  of  a  portion  of  its  substance  without  any  serious  injury ; 
but  a  similar  loss  of  substance  in  a  tooth  not  so  dense  in  struc- 
ture, would  be  likely  to  produce  inflammation  and  suppuration 
of  the  lining  membrane,  and  possibly  of  the  alveolo-dental 
periosteum.  Hence,  in  order  to  form  a  correct  opinion  of  the 
result  of  injuries  of  this  sort,  we  must  take  into  consideration, 
not  only  the  character  of  the  tooth  upon  which  the  blow  has 
been  inflicted,  but  also  the  state  of  the  mouth  and  the  health  of 
the  individual. 

If  the  tooth  is  not  loosened  in  its  socket,  any  injury  resulting 
from  the  loss  of  a  small  portion  of  the  enamel,  or  even  of  the 
dentine,  may  be  prevented  by  smoothing  the  fractured  surface 
with  a  file,  that  the  juices  of  the  mouth  and  particles  of  extra- 
neous matter  may  not  be  retained  in  contact  with  it.  But  if 
the  tooth  is  loosened,  and  inflammation  of  the  investing  mem- 
brane has  supervened,  leeches  should  be  applied  to  the  gums, 


414  INJURIES    FROM    MECHANICAL    VIOLENCE. 

and  the  mouth  washed  several  times  a  day  with  some  astringent 
lotion,  until  the  inflammation  subsides. 

When  a  tooth  lias  been  displaced  from  its  socket  by  a  blow, 
and  its  vascular  connection  with  the  general  system  destroyed, 
necrosis  must,  as  an  almost  necessary  consequence,  be  the  result. 
An  imperfect  union  between  the  tooth  and  alveolus  may  some- 
times be  re-established  by  the  effusion  of  coagulable  lymph,  and 
the  formation  of  an  imperfectly  organized  membrane ;  but  the 
tooth  will  ever  after,  from  the  slightest  cold,  or  derangement  of 
the  digestive  organs,  be  liable  to  become  sore  to  the  touch,  and 
in  most  cases  will  ultimately  assume  a  muddy-brown,  unhealthy 
appearance. 

The  author  has,  on  several  occasions,  replaced  teeth  that  had 
been  knocked  from  their  sockets ;  but  in  only  two  instances  was 
the  operation  attended  with  anj^thing  like  success.  The  subject 
in  one  case  was  a  healthy  boy,  of  about  thirteen  years  of  age, 
who,  while  playing  bandy,  received  a  blow  from  the  club  of  one 
of  his  playmates,  which  knocked  the  left  central  incisor  of  the 
upper  jaw  entirely  out  of  its  socket.  He  saw  the  boy  about 
fifteen  minutes  after  the  accident.  The  alveolus  was  filled  with 
coagulated  blood.  This  he  sponged  out,  and,  after  having 
bathed  the  tooth  in  tepid  water,  carefully  and  accurately  re- 
placed it  in  its  socket,  and  secured  it  there  by  silk  ligatures 
attached  to  the  adjacent  teeth.  On  the  following  day  the  gums 
around  the  tooth  were  considerably  inflamed,  to  reduce  which 
inflammation  he  directed  the  application  of  three  leeches  and 
the  frequent  use  of  diluted  tincture  of  myrrh  as  a  wash  for  the 
mouth.  At  the  expiration  of  four  weeks  the  tooth  became  firmly 
fixed  in  its  socket,  but  from  the  effusion  of  coagulable  lymph, 
the  alveolar  membrane  was  thickened,  and  the  tooth,  in  conse- 
quence, protruded  somewhat.  A  slight  soreness,  on  taking  cold, 
has  ever  since  been  experienced. 

Dr.  Noyes,  of  Baltimore,  mentioned  to  the  author  a  case  of  a 
somewhat  similar  character.  The  subject  was  a  boy  about  ten 
years  of  age.  One  of  his  front  teeth  was  forced  from  its  socket 
by  a  fall.  It  was  replaced  shortly  after,  and  in  a  few  weeks 
became  firm  in  its  alveolus.  Mr.  Bell  also  mentions  a  case 
attended  with  a  like  result. 

The  alveolar  processes  and  jaw-bones  are  sometimes  seriously 


INJURIES    FROM    MECHANICAL   VIOLENCE.  415 

injured  by  mechanical  violence.  In  1834,  the  author  was  re- 
quested by  the  late  Dr.  Baker,  of  Baltimore,  to  visit,  with  him, 
a  lady  who,  by  the  upsetting  of  a  stage,  had  her  face  severely 
bruised  and  lacerated.  All  that  portion  of  the  lower  jaw,  which 
contained  the  six  anterior  teeth,  was  splintered  off,  and  was  only 
retained  in  the  mouth  by  the  gums  and  integuments,  with  which 
it  was  connected.  The  wounds  of  her  face  having  been  properly 
dressed,  the  detached  portion  of  the  jaw  was  carefully  adjusted 
and  secured  by  a  ligature  passed  around  the  front  teeth  and  first 
molars,  and  by  a  bandage  on  the  outside,  around  the  chin  and 
back  part  of  the  head.  Her  mouth  was  washed  five  or  six  times 
a  day  with  diluted  tincture  of  myrrh.  The  third  day  after  the 
accident  Dr.  Baker  directed  the  loss  of  twelve  ounces  of  blood  ; 
and,  in  five  or  six  weeks,  with  no  other  treatment  than  the 
dressing  of  the  wounds,  she  perfectly  recovered. 

It  often  happens  that  the  crown  of  a  tooth  is  broken  off  at  the 
neck.  We  have  known  the  crowns  of  four,  and  in  one  case  of 
thirteen  teeth  to  be  fractured  by  a  single  blow.  The  subject  of 
the  last  case  was  a  fireman,  who,  in  1835,  received  an  accidental 
blow  on  his  mouth  from  the  head  of  an  axe,  which  broke  off  the 
crowns  of  all  the  upper  and  lower  incisors,  two  cuspids,  and 
three  of  the  bicuspids  of  the  inferior  maxilla.  The  subject  in 
the  other  case  Avas  a  boy  about  twelve  years  of  age,  who,  from  a 
similar  accident,  occasioned  by  running  up  suddenly  behind  a 
man  who  was  chopping  wood,  had  the  crowns  of  his  upper  in- 
cisors broken  off.  In  both  of  these  cases  the  inflammation  which 
supervened  was  so  great  as  to  render  the  removal  of  the  roots 
necessary.  The  crowns,  fangs,  and  alveolar  processes  are  some- 
times ground  to  pieces,  or  the  teeth  driven  into  the  very  sub- 
stance of  the  jaw.  Mr.  Bell  says  he  once  found  a  central  in- 
cisor so  completely  forced  into  the  bone,  that  he  thought  it  to 
be  the  remains  of  a  fang,  but,  on  removing  it,  found  it  to  be  an 
entire  tooth. 

When  the  crown  of  a  tooth  has  been  broken  off  by  a  blow,  the 
root  should,  as  a  general  rule,  be  immediately  extracted,  because 
the  injury  it  has  received  will  seldom  permit  it  to  remain  with 
impunity.  We  have  sometimes  engrafted  artificial  crowns  on 
such  roots,  but  the  practice  is  usually  a  bad  one.     If  the  tooth 


416  INJURIES    FROM    MECHANICAL    VIOLENCE. 

is  to  be  replaced  with  an  artificial  substitute,  the  root  should  be 
first  extracted :  in  some  cases,  however,  the  fang  may  be  filled 
and  a  tooth  set  upon  it,  not  by  pivot,  but  attached  to  a  plate. 

But  whether  the  loss  of  the  crown  be  replaced  or  not,  the  root 
can  seldom  remain  without  injury,  for  after  the  inflammation  in- 
duced by  the  concussion  of  the  blow  has  suflficiently  subsided,  or 
terminated  in  suppuration  of  the  lining  membrane,  which  it 
usually  does,  it  acts  as  a  morbid  irritant  to  the  socket  and  adja- 
cent parts,  and  for  this  reason  should  be  removed. 


CHAPTER     TWENTIETH. 
DISEASES  OF  THE  DENTAL  PULP  AND  PERIOSTEUM. 

The  pulp  of  a  tooth,  from  the  high  degree  of  vitality  with 
which  it  is  endowed,  is  one  of  the  most  sensitive  structures  of 
the  body,  and  like  other  parts  is  liable  to  become  the  seat  of 
various  morbid  phenomena.  Its  susceptibility  to  morbid  im- 
pressions is  influenced  by  a  variety  of  circumstances,  such  as 
temperament,  habit  of  body,  the  state  of  the  constitutional  health, 
the  condition  of  the  hard  structures  of  the  tooth,  etc.  A  cause, 
which  under  some  circumstances  would  not  be  productive  of  the 
slightest  disturbance,  might,  under  others,  give  rise  to  active  in- 
flammation, with  all  its  painful  and  disagreeable  concomitants. 
Increased  irritability  (hyperaesthesia)  may  exist  independently 
of  any  organic  change,  either  in  the  pulp,  dentine,  or  enamel. 
Examples  are  often  met  with  in  females  during  gestation ; 
but  it  arises  more  frequently  as  a  consequence  of  caries  than 
from  any  other  cause  connected  with  the  teeth.  Even  before 
the  disease  has  penetrated  to  the  central  chamber  of  the  organ, 
the  pulp  often  assumes  a  most  wonderful  and  marked  increase  of 
irritability,  either  from  functional  disturbance  arising  from  de- 
composition of  the  dentine,  impaired  relationship  between  the 
two,  or  from  being  more  exposed  to  the  action  of  external  dele- 
terious agents.  Impaired  digestion,  as  well  as  a  disordered  state 
of  other  functions  of  the  body,  frequently  produces  the  same 
effect. 

The  susceptibility  of  the  pulp  to  impressions  of  heat  and  cold, 
and  of  acids,  is  always  increased  by  heightened  irritability. 
When  this  exists  to  any  considerable  degree,  the  mere  contact 
of  these  agents  with  the  tooth  is  often  productive  of  severe  pain, 
which,  on  their  removal,  usually,  very  soon  subsides.  The  pulp, 
however,  may  remain  in  this  condition  for  months,  and  even 
years,  without  becoming  the  seat  of  inflammatory  action. 

Preternatural  sensibility  of  the  dentine,  whether  in  a  sound  or 


418       DISEASES    OF   THE    DENTAL    PULP    AND    PERIOSTEUM. 

partially  decomposed  state,  augments  very  appreciably  the  irrita- 
bility of  the  pulp.  The  sensibility  of  dentine  is  sometimes  so 
much  increased  that  the  mere  contact  of  any  hard  substance  with 
a  part  which  has  become  exposed  by  the  destruction  of  a  portion 
of  the  enamel,  is  often  productive  of  severe  pain.  Impressions 
of  heat  and  cold  conveyed  through  the  conducting  medium  of  a 
metallic  filling,  or  through  a  thin  covering  of  dentine,  as  some- 
times happens  when  a  considerable  portion  of  the  tooth  has  been 
worn  away,  is  also  a  very  frequent  cause  of  heightened  irrita- 
bility of  the  pulp.  With  its  susceptibility  thus  increased,  the 
impressions  produced  by  these  agents  are  often  a  source  of  irrita- 
tion, and  even  of  inflammation  and  suppuration,  causing  the 
death  of  the  entire  crown  and  inner  walls  of  the  root  of  the  tooth. 
At  other  times,  the  irritation  is  only  followed  by  slight  increase 
of  vascular  action  and  an  effusion  of  plastic  lymph  over  the 
affected  part  of  the  pulp,  which  is  gradually  converted  into  osteo- 
dentine ;  and  thus  a  barrier  is  interposed  between  it  and  the 
irritating  agents. 

IRRITATION. 

The  pulp  of  a  tooth  may  become  the  seat  of  severe  pain  even 
when  there  is  no  inflammation.  The  slightest  increase  of  vascu- 
lar action,  when  this  organ  is  in  a  preternaturally  irritable  con- 
dition, is  productive  of  more  or  less  irritation.  The  pressure  of 
the  slightly  distended  vessels  upon  the  nervous  filaments  dis- 
tributed upon  it,  at  such  times,  is  sufficient  to  cause  great  pain. 

Impressions  of  heat  and  cold  are  conveyed  more  readily  to  the 
pulp  when  the  dentine  is  in  a  morbidly  sensitive  condition,  and 
when  this  is  the  case,  they  produce  a  more  powerful  effect. 

The  remedial  indications  of  pain  in  a  tooth  arising  simply 
from  irritation  of  the  pulp,  consist  in  the  removal  of  the  primary 
and  exciting  causes.  When  produced  by  impressions  of  heat  and 
cold  conveyed  to  it  through  the  conducting  medium  of  a  metallic 
filling  and  intervening  supersensitive  dentine,  if  the  severity 
and  continuance  of  the  pain  is  such  as  to  warrant  the  belief  that 
it  will  give  rise  to  inflammation,  the  filling  should  be  removed 
and  some  non-conducting  substance  placed  in  the  bottom  of  the 
cavity  before  replacing  it.     If  this  is  done  before  inflammation 


DISEASES    OF   THE    DENTAL    PULP   AND    PERIOSTEUM.        419 

actually  takes  place,  it  will  prevent  subsequent  irritation  from 
these  causes.  It  is  worthy  of  remark,  however,  that  the  pain 
thus  produced,  is  in  proportion  to  the  sensibility  of  the  subjacent 
dentine.  If  this  is  destroyed  previously  to  filling  the  tooth, 
their  action  upon  the  pulp  will  be  as  effectually  prevented  as  by 
the  interposition  of  a  non-conducting  substance.  But  in  the 
application  of  agents  for  this  purpose,  there  is  danger  of  destroy- 
ing the  vitality  of  the  pulp.  The  employment  of  them,  however, 
is  resorted  to  more  frequently  to  prevent  pain  during  the  removal 
of  caries  than  to  relieve  any  subsequent  irritation  from  impres- 
sions of  heat  and  cold. 

Arsenious  acid,  cobalt,  chloride  of  zinc,  chloroform,  and  the 
actual  cautery  have  all  been  employed  in  the  treatment  of  sensi- 
tive dentine. 

The  use  of  arsenious  acid  in  dental  practice,  has  hitherto  been 
chiefly  confined  to  the  destruction  of  the  vitality  of  the  pulps  of 
teeth,  but  it  will  also  destroy  the  sensibility  of  the  dentine,  and 
thus  enable  the  operator  to  remove,  without  pain,  the  semi- 
decomposed  parts  of  a  sensitive  carious  tooth,  preparatory  to 
filling.  In  employing  it  for  this  purpose,  however,  great  care  is 
necessary  to  prevent  the  destruction  of  the  vitality  of  the  pulp, 
and  the  injection  of  the  vessels  of  the  dentine.  This  is  very 
liable  to  happen  when  applied  to  a  tooth  of  a  very  soft  texture, 
especially  if  in  the  mouth  of  a  young  person,  and  when  the 
caries  extends  nearly  to  the  pulp-cavity.  The  action  of  arsenic, 
through  the  intervening  hard  structures,  on  the  pulp,  would  seem, 
in  the  first  instance,  to  cause,  in  some  way,  the  decomposition  of 
the  red  globules  of  the  blood  ;  whereby  a  pinkish-purple  tinge  is 
imparted  to  the  serous  portion  of  this  fluid,  which  is  conveyed  to 
every  part  of  the  dentine.  It  seems,  also,  to  exert  some  peculiar 
action  upon  the  microscopic  vessels  of  this  tissue ;  for  the  fluid 
which  they  circulate  is  now  evidently  everywhere  eff"used  from 
their  coats  and  brought  into  direct  contact  with  the  earthy  salts, 
coloring  them  so  deeply  as  to  impart  to  the  crown  of  the  tooth 
a  pinkish  or  purple  hue,  distinctly  seen  through  the  translucent 
enamel  covering.  Three  or  four  cases  in  which  this  has  happened 
have  occurred  in  the  practice  of  the  author. 

But  the  application  of  arsenic  to  a  tooth  is  not  necessarily 
followed  by  this  eff"ect.    It  is  only  in  young  persons,  and  in  teeth 


420       DISEASES    OF   THE    DJENTAL    PULP   AND    PERIOSTEUM. 

of  a  very  soft  texture,  tliat  this  is  liable  to  occur,  unless  per- 
mitted to  remain  in«  the  tooth  for  a  long  time.  When  it  is  used 
merely  for  the  purpose  of  destroying  the  vitality  of  the  surface 
of  the  dentine  at  the  bottom  of  the  cavity,  preparatory  to  the 
introduction  of  a  filling,  and  to  prevent  irritation  of  the  pulp 
from  impressions  of  heat  and  cold,  it  should  never  be  permitted 
to  remain  more  than  two  hours.  At  the  expiration  of  this  time 
it  should  be  removed,  and  after  thoroughly  washing  and  drying 
the  cavity,  the  filling  may  be  introduced,  without  danger  of  sub- 
sequent irritation  of  the  pulp  or  discoloration  of  the  tooth.  The 
thirtieth,  fortieth,  or  even  fiftieth  part  of  a  grain,  with  an  equal 
quantity  of  sulphate  of  morphia,  is  sufiicient  to  apply  to  a  tooth. 
It  should  be  put  on  a  dossil  of  raw  cotton  or  lint  moistened  with 
creosote,  and  placed  directly  upon  the  bottom  of  the  cavity. 
After  the  arsenic  has  been  applied,  the  cavity  should  be  carefully 
filled  with  wax,  mastic,  or  Hill's  stopping,  to  prevent  the  possi- 
bility of  its  escaping  into  the  mouth  and  to  exclude  the  buccal 
fluids.  When  the  cavity  is  on  the  approximal  surface  of  the 
tooth,  additional  security  may  be  obtained  by  passing  a  ligature 
of  floss  silk  three  or  four  times  around  it  and  tying.  A  small 
ring  cut  from  the  end  of  a  tube  of  caoutchouc  placed  on  the 
tooth  is  even  better  than  a  ligature  of  silk. 

Dr.  Arthur  recommends  the  use  of  cobalt  for  destroying  morbid 
sensibility  of  dentine.  He  has  used  it  for  several  years,  and 
believes  it  to  be  as  certain  in  its  eff'ects  as  arsenious  acid  and  less 
liable  to  injure  the  pulp  of  the  tooth.  It  is  the  arsenic,  how- 
ever, with  which  the  cobalt  is  combined  that  produces  the  effect ; 
but  he  thinks  that  its  union  with  the  cobalt  renders  it  less  liable 
to  be  taken  into  the  dentine  by  absorption,  and  as  a  consequence, 
less  liable  to  produce  a  deleterious  action  upon  the  pulp.  It  is 
used  in  the  form  of  a  brownish-black  oxyd,  reduced  to  a  fine 
powder,  and  applied  to  the  tooth  in  the  same  manner  as  arsenious 
acid. 

For  the  destruction  merely  of  morbid  sensibility  in  the  solid 
structures  of  a  tooth,  chlorid  of  zinc,  according  to  the  author's 
experience,  although  somewhat  less  certain  in  its  effects,  is 
superior  to  any  preparation  dependent  for  its  active  properties 
upon  the  presence  of  arsenic.  With  this  agent  it  rarely  happens 
that  more  than  five  minutes  are  required  to  obtain  the  desired 


DISEASES    OF   THE    DENTAL    PULP   AND    PERIOSTEUM.        421 

effect.  Although  a  powerful  escharotic,  it  does  not,  as  all 
arsenical  preparations  are  liable  to  do,  produce  any  deleterious 
effect  on  the  pulp  of  the  tooth.  It  is  thought,  however,  in  some 
cases  to  modify  the  texture  of  the  dentine ;  and,  in  the  opinion 
of  some  practitioners,  so  much  so  as  to  render  it  more  easily 
acted  upon  by  decaying  agencies.  When  first  applied,  it  excites 
a  sensation  of  heat,  followed  by  burning  pain,  but  these  soon 
subside,  and  on  removing  it  from  the  tooth,  the  parts  of  the 
cavity  with  which  it  was  in  contact,  will,  in  a  large  majority  of 
the  cases,  be  found  totally  insensible  to  the  touch  of  an  instru- 
ment. Dr.  F.  N.  Seabury  relates  a  case  in  which  he  applied  it 
directly  to  the  exposed  pulp  of  an  aching  tooth.  The  pain, 
which  at  first  was  increased,  soon  subsided,  and  after  removing 
the  chlorid,  the  tooth  was  filled  in  the  usual  way,  without  incon- 
venience to  the  patient. 

The  chlorid  may  be  applied  directly  to  the  cavity  of  a  sensi- 
tive tooth,  without  being  combined  with  any  other  substance,  on 
a  little  raw  cotton  or  lint ;  or  it  may  be  made  into  a  paste  by 
mixing  it  with  an  equal  quantity  of  flour,  the  moisture  which  it 
absorbs  from  the  atmosphere  being  suSicient  for  the  formation  of 
the  paste  ;  or  it  may  be  mixed  with  a  little  pure  anhydrous  sulphate 
of  lime,  in  an  impalpable  powder,  and  then  applied  to  the  tooth. 
But  before  this  is  done,  as  much  of  the  decomposed  dentine  as 
possible  should  be  removed,  and  the  application  should  be  held 
firmly  in  contact  with  the  part  of  the  cavity  upon  which  it  is  in- 
tended to  act.  This  may  be  done  by  filling  the  cavity  after  it 
has  been  put  in,  with  softened  wax  or  raw  cotton.  The  chlorid 
may  remain  in  the  tooth  from  five  to  ten  minutes,  or  until  the 
burning  sensation  produced  by  it  ceases.  A  single  application 
will  generally  suffice  to  destroy  the  sensibility  of  the  walls  of  the 
cavity  to  a  sufficient  depth  to  enable  the  operator  to  remove  any 
remaining  portions  of  decayed  dentine  without  pain,  and  to  obtund 
the  vitality  of  the  floor  of  the  cavity  sufficiently  to  prevent  the 
transmission  of  impressions  of  heat  and  cold  to  the  pulp.  A 
second,  and  even  a  third  application,  however,  will  sometimes  be 
required.  We  have  before  referred  to  the  local  action  of  chloro- 
form. It  is  brief  in  its  effect,  and  calls  for  repeated  application 
in  a  long  operation,  but  has  the  advantage  of  being  totally  free 
from  the  possibly  injurious  action  of  arsenic,  cobalt  and  oxyd 
of  zinc. 


422       DISEASES    OF    THE    DENTAL    PULP    AND    PERIOSTEUM. 

The  actual  cautery  was  at  one  time  much  used  and  highly  re- 
commended by  French  dentists  in  the  treatment  of  sensitive  de- 
cayed teeth,  but  as  the  application  gave  rise,  very  often,  to  in- 
flammation of  the  pulp,  its  use  in  England  and  America  was  long 
since  laid  aside. 

Less  potent  agents,  such  as  pulverized  galls,  tannic  acid,  &c., 
have  been  employed  for  the  purpose  of  destroying  morbid  sensi- 
bility in  teeth  preparatory  to  filling,  and  sometimes  with  good 
results. 

Having  noticed  the  agents  usually  employed  for  destroying 
morbid  sensibility  in  dentine,  we  will  proceed  to  notice  a  few  of 
the  non-conductors  of  caloric  that  have  been  used  for  the  accom- 
plishment of  the  same  object.  Among  the  substances  which 
have  been  employed  for  this  purpose,  are,  asbestos,  gutta  percha^ 
HilVs  stopping,  cork  and  oiled  silk. 

Asbestos,  as  a  non-conductor  of  caloric,  certainly  possesses 
every  desirable  property,  and  is  as  indestructible  in  a  tooth  as 
gold.  When  used  for  this  purpose,  the  purest  variety  should  be 
selected.  A  small  pellet,  made  from  the  filaments  of  this  mine- 
ral, placed  in  the  bottom  of  a  cavity  previously  to  filling,  will 
efi'ectually  prevent  irritation  of  the  pulp  from  impressions  of  heat 
and  cold.  The  cavity,  however,  should  be  first  -properly  pre- 
pared, washed  with  tepid  water  and  made  perfectly  dry.  The 
asbestos  may  occupy  from  one-fourth  to  one-sixth  of  the  depth 
of  the  cavity  after  the  filling  has  been  introduced  and  consoli- 
dated. 

A  thin  layer  of  gutta  percha  placed  in  the  bottom  of  the  cavity, 
previously  to  introducing  the  gold,  is  as  efi"ectual  in  preventing 
the  transmission  of  impressions  of  heat  and  cold,  as  asbestos, 
and  can  be  more  conveniently  applied.  There  is,  however,  a 
preparation  of  it,  known  as  "Hill's  stopping,"  better  than  the 
simple  article.  The  method  of  applying  it  is  very  simple.  The 
cavity  being  first  properly  prepared,  a  small  piece  of  this  pre- 
paration is  slightly  warmed  by  a  fire,  or  by  the  flame  of  a  candle 
or  lamp,  then  placed  in  the  bottom  of  the  cavity  and  adapted  to 
its  inequalities  by  pressing  on  it  gently  with  a  large  broad-pointed 
plugger.  This  done,  the  cavity  may  be  filled  with  gold  in  the 
usual  manner. 

Cork,  though   an  equally  good  non-conductor  of  caloric,  is 


DISEASES    OF    THE    DENTAL    PULP    AND    PERIOSTEUM.        423 

thought  by  some,  as  it  is  raoi-e  destructible  than  asbestos  or  gutta 
percha,  to  be  objectionable  ;  but  cut  off,  as  it  necessarily  would 
be  in  the  bottom  of  the  cavity  beneath  the  filling,  its  liability  to 
undergo  any  change,  would  seem  to  be  rendered  wholly  impossi- 
ble. It  is  objected  to  its  use,  that  it  is  of  a  more  porous  nature 
than  gutta  percha,  and  cannot  be  adapted  as  perfectly  to  the  in- 
equalities of  the  floor  of  the  cavity.  Also  that  there  is  danger 
in  introduced  the  filling  of  forcing  some  portions  of  the  gold 
through  it,  unless  a  very  thick  piece  be  used.  Oiled  silk  has 
also  been  used  in  some  cases  very  successfully,  but  it  is  not  as 
good  a  non-conductor  as  any  of  the  afore-mentioned  agents. 

But  a  metallic  filling  is  not  the  only  medium  through  which 
impressions  of  heat  and  cold  are  conveyed  to  the  dental  pulp. 
When  the  dentine  on  the  coronal  extremity  or  side  of  a  tooth 
becomes  very  thin  from  loss  of  substance,  occasioned  by  mechani- 
cal or  spontaneous  abrasion,  by  the  use  of  the  file,  erosion,  or 
other  cause,  the  pulp  sometimes  becomes  painfully  susceptible 
to  the  action  of  these  agents.  Loss  of  substance  from  any  of 
these  causes,  is  also  often  attended  by  exalted  sensibility  of  the 
exposed  dentine ;  and  when  this  is  the  case,  the  contact  of  acids 
with  it  is  productive  of  more  or  less  pain.  Nature,  however, 
usually  prevents  the  painful  consequences  that  would  naturally 
arise  from  continued  abrasion  of  the  coronal  ends  of  the  teeth 
and  the  consequent  exposure  of  their  nervous  pulp,  by  the  gradual 
ossification  of  this  organ ;  so  that  by  the  time  it  would  become 
exposed,  it  is  converted  into  osteo-dentine.  But  this  does  not 
always  take  place  in  time  to  prevent  irritation  and  pain. 

When  irritation  of  the  pulp  occurs  in  a  tooth  that  has  been 
filed  on  one  or  both  sides,  so  much  so  as  to  leave  only  a  thin 
covering  of  dentine,  the  best  known  means  of  preventing  morbid 
sensibility  is,  to  keep  the  filed  surface  constantly  clean  by 
frequent  friction,  with  a  brush  and  waxed  floss  silk,  or  with  some 
other  suitable  substance.  This  operation  should  be  repeated 
after  each  meal,  and  in  the  morning  immediately  after  rising, 
and  at  night  before  going  to  bed. 

When  caries  has  extended  to  the  central  cavity,  irritation  is 
often  produced  by  contact  of  partially  decomposed  portions  of 
dentine  or  other  foreign  matter  with  the  pulp.  The  proper 
remedial  indication  in  such  cases,  it  is  scarcely  necessary  to  say. 


424  INFLAMMATION    OF    THE    DENTAL    PULP. 

consists  in  the  removal  of  all  matter  from  the  tooth  that  can  act 
either  as  a  mechanical  or  chemical  irritant.  This  done,  the 
cavity  in  the  tooth,  supposing  the  pulp  to  be  in  a  healthy  condi- 
tion, should  be  properly  filled. 

But  when  the  irritation  arises  as  a  consequence  of  exalted 
irritability  and  increased  vascular  action  of  the  pulp,  dependent 
upon  disease  or  altered  function  of  some  other  part  or  parts  of 
the  body,  the  remedial  indications  are  different.  The  treatment 
then  should  be  addressed  to  the  primary  affection.  Examples  of 
this  sort  are  of  frequent  occurrence.  They  are  met  with  almost 
daily,  particularly  in  females  during  gestation,  in  dyspeptic 
individuals,  and  in  persons  affected  with  gout  and  chronic  rheu- 
matism. They  are  also  sometimes  met  with  in  individuals  who 
have  been  exposed  to  miasmatic  emanations  of  marshy  districts, 
when  the  irritation  assumes  an  intermittent  form,  occurring  at 
stated  intervals  of  twenty-four,  forty-eight  or  seventy-two  hours, 
and  continuing  from  one  to  three  hours.  Some  of  the  worst 
forms  of  tooth-ache  are  produced  by  one  or  other  of  these  causes. 

The  local  disturbance,  when  it  occurs  in  females  during  preg- 
nancy, may  generally  be  removed  by  mild  aperients,  warm  foot- 
bath and  anodynes  at  night  on  going  to  bed.  When  it  depends 
upon  other  kinds  of  derangement  of  the  uterine  organs,  treatment 
suited  to  the  peculiar  indications  of  the  case  should  be  instituted. 
When  it  occurs  in  a  person  affected  with  dyspepsia,  rheumatism 
or  gout,  the  constitutional  treatment  required  by  the  particular 
disease,  constitutes  the  proper  remedy.  AYhen  the  irritation 
assumes  an  intermittent  form,  an  emetic  or  cathartic,  followed  by 
quinine,  will  generally  put  a  stop  to  the  local  disturbance,  pro- 
vided it  has  no  connection  with  caries  of  the  crown  of  the  tooth. 

INFLAMMATION. 

The  pulp  of  a  tooth,  when  healthy,  has  a  grayish-white  ap- 
pearance, and  its  capillaries  are  invisible  to  the  naked  eye,  but 
when  it  becomes  the  seat  of  acute  or  active  inflammation,  they 
may  be  distinctly  seen  ;  the  organ  then  assumes  a  bright  red 
color.  Inflammation  having  established  itself,  soon  extends  to 
every  part  of  the  pulp,  and  even  to  the  alveolo-dental  periosteum. 
When  permitted  to  run  its  course  uninterruptedly,  it  usually 
terminates  in  suppuration  in  from  three  to  eight  or  ten  days. 


INFLAMMATION    OF   THE    DENTAL    PULP.  425 

The  unyielding  nature  of  the  ■walls  of  the  cavity  in  which  it 
is,  on  all  sides,  enclosed,  renders  expansion  of  the  pulp  impos- 
sible, and  as  its  capillaries  become  distended  with  blood,  they 
press  on  the  nervous  filaments  which  are  everywhere  distributed 
upon  it,  causing  at  first  constant  gnawing  pain ;  which  after- 
ward, as  the  distension  of  the  vessels  increases,  becomes  severe, 
deep-seated,  throbbing,  and  sometimes  almost  insupportable. 

Inflammation  may  attack  the  pulps  of  sound  teeth  as  well  as 
those  affected  with  caries  ;  but  it  occurs  more  frequently  in  the 
latter  than  in  the  former,  and  it  is-  oftener  met  with  before  than 
after  the  pulp  has  become  actually  exposed.  The  severity  of 
the  pain,  however,  is  determined  by  the  condition  of  the  tooth, 
the  state  of  the  general  health,  and  the  causes  concerned  in  its 
production.  The  pulp,  when  in  an  irritable  condition,  is  more 
liable  to  become  the  seat  of  acute  inflammation,  than  when  in  a 
perfectly  healthy  state,  and  the  occurrence  of  suppuration  is  soon 
followed  by  alveolar  abscess,  unless  an  opening  is  made  im- 
mediately through  the  crown,  neck  or  root  of  the  tooth,  for  the 
escape  of  the  matter. 

The  effusion  of  lymph  which  takes  place  during  the  inflamma- 
tory stnge,  and  which,  under  other  circumstances,  and  when  the 
inflammation  is  less  severe,  is  made  to  play  an  important  part 
in  the  reparation  of  the  injury,  compresses  the  pulp  into  still 
narrower  limits  as  it  accumulates  in  quantity,  and  thus  becomes 
an  additional  source  of  irritation,  adding  fuel  to  the  flame 
already  lighted  up. 

Inflammation  of  the  pulp  may  be  caused  by  a  blow  on  the 
tooth;  by  impressions  of  heat  and  cold  conveyed  to  it  through 
the  enamel  and  dentine,  or  through  a  metallic  filling ;  or  by  the 
pressure  of  a  filling,  or  the  direct  contact  of  external  irritating 
agents,  such  as,  disorganized  portions  of  the  tooth,  particles  of 
iilinientary  substances,  acrid  humors,  etc.  But,  as  we  have 
stated  in  another  place,  inflammation  of  the  dental  pulp  is  not 
always  a  necessary  consequence  of  impressions  of  heat  and  cold; 
pain  may  be  produced  by  them  when  it  does  not  exist,  but  in 
this  case  it  usually  subsides  soon  after  the  removal  of  the  irri- 
tant. The  pulp  of  a  tooth  may  be  exposed  for  months,  and 
subjected  several  times  a  day  to  the  actual  contact  of  foreign 
bodies,  without  becoming  the  seat  of  acute  inflammation.  The 
28 


426  INFLAMMATION    OF    THE    DKNTAL    PULP. 

irritation  and  increased  vascular  action  thus  occasioned,  are,  no 
doubt,  removed  by  the  effusion  of  lymph  to  which  they  give 
rise,  and  the  pulp,  after  it  has  become  exposed,  having  room  to 
expand  as  its  vessels  become  distended,  does  not  suffer  irritation 
from  the  pressure  to  which  it  would  otherwise  be  subjected. 

When  suppuration  takes  place,  the  pain  very  nearly  ceases, 
but  the  tooth  for  a  time  remains  sore  to  the  touch,  and  its 
appearance  is  changed.  It  has  no  longer  the  peculiar  animated 
translucency  of  a  living  tooth,  but  has  assumed  an  opaque, 
muddy  or  brownish  aspect.  With  the  disorganization  of  the 
pulp,  the  entire  crown  and  inner  walls  of  the  root  lose  their 
vitality;  still,  if  the  alveolo- dental  periosteum  has  not  become 
seriously  involved  in  disease,  the  vascular  and  nervous  supply 
furnished  to  the  cementum  is  often  sufficient  to  prevent  the  tooth 
from  exerting  any  injurious  influence  upon  the  surrounding 
and  more  highly  vitalized  parts.  The  cementum  being  more 
analogous  in  structure  to  true  osseous  tissue  than  dentine,  now 
plays  an  important  part  in  the  animal  economy.  It  being  more 
liberally  supplied  with  vitality  and  with  nutritive  juices,  and  not 
being  sensibly  affected  by  the  death  of  the  other  parts  of  the 
organ,  it  keeps  up  the  living  relationship  of  the  tooth  with  the 
alveolo-dental  periosteum,  at  least  sufficiently  to  prevent  it  from 
acting  perceptibly  as  a  morbid  irritant. 

Inflammation  of  the  pulp  of  a  tooth,  besides  the  local  pain 
with  which  it  is  attended,  often  gives  rise  to  a  train  of  constitu- 
tional morbid  phenomena,  usually  of  a  mild,  but  sometimes  of 
an  aggravated  and  even  threatening  character.  Among  these 
are  head-ache,  constipation  of  the  bowels,  furred  tongue,  dryness 
of  the  skin,  quick,  full  and  hard  pulse,  ear-ache,  ophthalmia, 
disease  of  the  maxillary  sinus,  etc. 

The  amount  of  constitutional  disturbance  arising  from  inflam- 
mation of  the  pulp  of  a  tooth,  depends  on  the  state  of  the 
general  health,  and  the  nervous  irritability  of  the  system  at  the 
time.  In  the  majority  of  cases  it  occasions  but  little  inconveni- 
ence, and  disappears  as  soon  as  the  inflammation  ceases,  but 
sometimes  it  assumes  a  very  alarming  character.  A  fatal  case 
of  tetanus,  produced  by  inflammation  of  the  pulp  of  a  lower 
molar,  occurred  a  few  years  ago  in  Baltimore.  The  subject  was 
a  young  lady  about  eighteen  years  of  age.     The  system,  at  the 


INFLAMMATION    OF    THE    DENTAL    PULP,  427 

time,  from  great  bodily  fatigue  and  mental  excitement,  was  in 
an  exceedingly  irritable  condition,  but  in  other  respects,  though 
constitutionally  rather  delicate,  she  was  in  the  enjoyment  of 
good  health. 

There  is  not  an  organ  or  tissue  of  the  body  in  which  acute 
inflammation  is  more  intractable  in  its  nature,  and  rapid  in  its 
progress,  than  in  the  pulp  of  a  tooth  ;  and,  when  we  take  into 
consideration  its  situation,  and  its  physical  and  vital  peculiari- 
ties, it  is  not  to  be  wondered  that  it  should,  in  so  large  a 
majority  of  the  cases,  terminate  in  the  disorganization  of  the 
part.  Still,  it  may  sometimes  be  arrested,  and  the  remedial 
indications  here,  though  they  cannot  be  as  readily  and  fully 
carried  out,  are  the  same  as  for  inflammation  in  any  other  part 
i>f  the  body.  The  first  and  most  important  one  consists  in  the 
removal  of  all  local  and  exciting  causes.  If  it  be  the  result  of 
irritation  produced  by  the  pressure  of  a  filling,  the  plug  should 
be  immediately  removed,  leeches  applied  to  the  gum  of  the 
aff'ected  tooth,  and,  if  the  patient  be  of  a  full  habit,  blood  may 
be  taken  from  the  arm,  and  a  brisk  saline  purgative  prescribed. 
The  removal  of  the  filling,  however,  when  the  inflammation  has 
previously  made  much  progress,  will  not  prevent  suppuration, 
but  it  may  keep  it  from  extending  to  every  part  of  the  pulp. 
When  an  external  opening  is  made  for  the  escape  of  the  matter 
the  moment  suppuration  takes  place,  the  remaining  portion  of 
the  pulp  will  be  relieved  from  the  pressure  which  caused  the 
irritation,  and  then  the  inflammatory  action  may  cease.  But  if 
the  matter  remains  in  the  central  cavity  of  the  tooth,  the  part 
of  the  pulp  which  has  not  suppurated  will  still  be  subjected  to 
pressure,  and  the  inflammation  and  suppuration  will  go  on  until 
the  entire  organ  perishes.  Nor  will  the  disorganizing  process 
stop  here.  The  alveolo-dental  membrane,  at  the  extremity  of 
the  root,  will  soon  become  implicated,  and  in  a  short  time  alveo- 
lar abscess  will  form,  thus  terminating  the  acute  stage  of  the 
disease. 

There  may  be  no  indications  of  irritation  or  inflammation  for 
several  weeks,  or  even  months,  after  a  tooth  has  been  filled ;  but 
at  the  expiration  of  this  time,  the  pulp,  from  increased  irrita- 
bility, caused,  perhaps,  by  some  change  in  the  state  of  the 
patient's   general    health,   may  be    attacked   by  inflammation. 


428  INFLAMMATION    OF    THE    DENTAL    PULP. 

Although  this  very  seldom  happens,  it  does,  nevertheless,  some- 
times occur.  When  there  is  reason  to  apprehend  that  it  is  about 
to  take  place — and  it  may  be  suspected  if  pain  is  felt  in  the  tooth 
when  anything  hot  or  cold  is  taken  into  the  mouth,  or  if  it  be- 
comes the  seat  of  gnawing  or  gradually  increasing  pain — the 
filling  should  be  removed.  If  the  pain  now  ceases,  a  thick  layer 
of  gutta  percha,  or  "Hill's  stopping,"  may  be  placed  in  the 
bottom  of  the  cavity,  and  the  filling  replaced  ;  using  the  precau- 
tion, as  before  directed,  to  introduce  the  gold  in  such  a  way  as 
to  prevent  the  liability  of  depressing  the  floor  of  the  cavity. 
But  if  the  pain  and  inflammation  continue  unabated,  it  may  be 
necessary  to  extract  the  tooth,  or  expose  the  pulp  and  destroy 
its  vitality  by  applying  to  it  some  powerful  escharotic,  as  arseni- 
ous  acid ;  which,  acting  more  promptly  and  with  more  certainty 
than  any  other,  seems  best  adapted  to  the  purpose.  When  this 
is  done,  it  is  usually  with  the  view  of  securing  the  retention  and 
preservation  of  the  tooth  by  filling  the  pulp-cavity  and  root,  an 
operation  now  very  frequently  performed  by  many  dentists. 

The  abstraction  of  blood  directly  from  the  pulp,  one  might 
suppose,  would  be  better  calculated  to  arrest  the  inflammation 
than  almost  any  other  treatment ;  but  we  do  not  think  this  has 
been  resorted  to  for  this  purpose  sufficiently  often  to  determine 
its  therapeutic  value.  At  any  rate,  it  seems  reasonable  to  sup- 
pose that  if,  by  this  means,  the  congestion  of  the  capillaries  could 
be  removed,  the  tumefied  pulp  would  be  reduced  to  its  natural 
size,  and  be  relieved  from  the  pressure  to  which,  as  a  consequence 
of  its  distended  condition,  it  is  subjected.  To  obtain  the  largest 
amount  of  benefit  capable  of  being  derived  from  the  operation, 
the  opening  should  be  made  in  that  portion  where  one  of  the 
principal  arteries  would  be  most  likely  to  be  punctured ;  and 
this,  it  seems  to  us,  would  be  just  where  the  canal  of  the  root 
enters  the  chamber  of  the  crown  of  the  tooth.  But  in  making 
the  puncture  here,  the  pulp  being  very  small  at  this  point,  there 
is  danger  of  cutting  it  ofi";  and  as  reunion  would  scarcely  be 
likely  to  take  place,  the  portion  in  the  central  cavity  would  neces- 
sarily perish. 

If  the  pulp  were  exposed,  there  would  be  a  better  opportunity 
of  relieving  the  congested  condition  of  its  capillaries  by  the  ab- 
straction of  blood ;  but  the  difficulty  of  obtaining  free  access  to 


INFLAMMATION  OF  THE  DENTAL  PULP.         429 

the  organ  by  drilling  a  hole  through  the  intervening  dentine  is 
very  great ;  the  tooth,  when  suffering  from  inflammation,  being 
usually  so  sore  to  the  touch  that  the  slightest  pressure  is  produc- 
tive of  great  pain  ;  hence,  the  operation  will  seldom  if  ever  prove 
successful.  Unless,  therefore,  the  retention  of  the  tooth  is  a 
matter  of  more  than  ordinary  importance,  it  is  better  to  remove 
it  at  once.  If  it  is  an  incisor  or  cuspid,  the  pulp  should  be  im- 
mediately extirpated  or  arsenious  acid  applied  for  the  destruc- 
tion of  its  vitality  ;  or,  if  suppuration  has  previously  taken  place, 
an  opening  should  be  made  into  the  chamber  of  the  tooth  as  be- 
fore directed,  for  the  escape  of  the  matter.  Should  it  be  found, 
after  this  has  escaped,  that  disorganization  has  not  extended  to 
every  part  of  the  pulp,  the  remaining  portion  may  be  destroyed 
in  the  manner  above  described.  This  done,  the  pulp-cavity  and 
root,  as  soon  as  the  inflammation  of  the  socsket  has  completely 
subsided,  may  be  filled. 

It  will  be  seen  from  the  foregoing  remarks,  that  it  is  only  at 
its  very  inception,  that  there  is  any  chance  of  combating  suc- 
cessfully acute  inflammation  of  the  pulp  of  a  tooth  ;  and  even 
then,  so  rapid  is  the  progress  of  the  disease,  it  may  baflfle  the 
best  directed  and  most  energetic  treatment,  that  can  be  adopted. 
It  may  be  that  when  attention  shall  have  become  more  generally 
directed  to  the  subject,  some  more  successful  method  of  treat- 
ment may  be  discovered  ;  but  that  a  complete  mastery  over  the 
disease  will  ever  be  obtained,  is  not  to  be  expected. 

Inflammation  of  the  dental  pulp  is  not  always  acute  ;  it  some- 
times assumes  a  chronic  and  local  form.  This  often  occurs 
where  the  chamber  of  a  tooth  has-  become  gradually  exposed  by 
caries  of  the  dentine ;  and  when  this  happens,  the  action  of  the 
fluids  of  the  mouth,  and  of  other  foreign  substances  which  obtain 
access  to  the  cavity,  as  well  as  of  the  decomposed  portions  of  the 
tooth  substance,  causes  an  increase  of  vascular  action  in  the  ex- 
posed part,  followed,  very  often,  by  a  slight  discharge  ;  but  the 
morbid  action  thus  induced  is,  comparatively,  seldom  accompanied 
by  pain.  The  pulp  may  remain  thus  partially  exposed  for 
months,  and  even  years,  without  causing  any  other  inconveni- 
ence than  a  momentary  twinge  of  pain  when  some  hard  sub- 
stance is  accidentally  introduced  into  the  cavity  of  the  tooth, 
which  subsides  immediately  after  its  removal.     Sooner  or  later. 


430  INFLAMMATION    OF    THE    DENTAL    PULP. 

however,  the  pain  thus  excited  will  become  more  permanent, 
continuins:  each  time  it  occurs,  from  five  or  ten  minutes  to  one 
or  more  hours  after  the  cause  of  the  irritation  has  been  removed. 
If  a  tooth  be  filled  under  such  circumstances,  the  pressure  of 
the  fluid  upon  the  pulp,  which  is  poured  out  from  its  exposed 
surface  beneath  the  plug,  will  give  rise  to  a  more  general  and 
active  form  of  inflammatory  action. 

The  liability  of  the  tooth  to  ache  increases  as  the  pulp  be- 
comes more  and  more  exposed  by  the  gradual  decomposition  of 
the  dentine  ;  and  the  inflammation  may  ultimately  assume  a  more 
active  form,  or  the  pulp  may  become  the  seat  of  fungous  growth, 
or  it  may  be  absorbed  or  destroyed  by  ulceration,  or  by  gangrene 
and  mortification.  Cases  sometimes  occur  in  which  the  disease 
is  attended  with  severe  darting  pains,  often  occurring  several  times 
in  the  space  of  two  or  three  minutes,  succeeded  by  intervals  of 
perfect  ease  for  many  hours.  At  other  times  it  is  attended  by 
dull  aching  pain,  aggravated  by  taking  sweet  or  acid  substances 
into  the  mouth.  In  cases  of  this  sort,  the  application  of  heating 
or  stimulating  substances  to  the  exposed  surface  of  the  pulp  will 
usually  procure  relief.  Permanent  exemption  from  pain,  how 
ever,  is  rarely  obtained,  and  sooner  or  later,  it  becomes  necessary 
either  to  destroy  the  pulp  or  to  extract  the  tooth. 

The  body  of  the  pulp  when  the  organ  becomes  exposed  from 
a  decayed  opening  in  the  grinding  surface  of  a  molar,  is  some- 
times absorbed,  while  its  prolongations  in  the  roots  often  remain 
unchanged  for  two  or  more  years. 

Chronic  inflammation  of  an  exposed  surface  of  the  pulp,  when 
long  continued,  sometimes  gives  rise  to  ulceration — a  disorganizing 
process,  which  often  causes  the  destruction  of  a  large  portion  of 
the  part  occupying  the  central  chamber  of  the  crown  of  the  tooth, 
making  in  it  numerous  little  excavations.  The  ulcerated  surface 
usually  presents  a  yellowish  appearance  ;  when  the  disorganizing 
process  is  arrested  before  it  has  eff"ected  the  destruction  of  any 
very  large  portion  of  the  pulp,  it  usually  becomes  covered  with 
healthy  granulations. 

^\  hen  the  inflammation  occurs  in  cachectic  individuals  it  often 
assumes  an  acute  form,  and  sometimes  terminates  in  gangrene 
and  mortification.  The  loss  of  vitality  may  be  confined  to  the 
body  of  the  pulp,  or  it  may  extend  to  every  part  of  the  organ. 


INFLAMMATION    OF    THE    DENTAL    PULP.  431 

In  the  former  case  the  pain  continues,  but  in  the  Luter  it  ceases 
as  soon  as  mortification  takes  place.  When  this  happens,  the 
entire  pulp,  which  has  now  a  dark  brown  or  black  color,  may  be 
removed.     But  this  is  not  a  very  common  termination. 

The  symptoms  of  chronic  as  well  as  acute  inflammation  are 
always  modified  by  the  state  of  the  general  health,  habit  of  body, 
and  the  temperament  of  the  individual.  The  pain  attending  the 
former,  however,  is  periodical,  occurring  at  irregular  and  un- 
certain intervals,  and  constitutes  that  variety  of  tooth-ache  so 
often  relieved  by  local  application's ;  whereas,  in  the  latter,  it  is 
constant. 

In  chronic  inflammation,  the  pulp  is  either  actually  exposed 
or  only  covered  by  decomposed  or  paitially  decomposed  dentine, 
and  the  diseased  surface  rarely  embraces  a  larger  circumference 
than  that  described  by  the  bottom  of  the  decayed  cavity.  The 
inflammation,  therefore,  is  local  as  well  as  chronic,  but,  never- 
theless, it  is  often  of  so  persistent  a  character,  as  to  render  its 
removal  exceedingly  difficult.  The  dentist,  however,  is  not  so 
much  restricted  in  the  application  of  remedies  as  in  the  treat- 
ment of  acute  inflammation,  and  to  the  action  of  Avhich  it  yields 
more  readily.  But  notwithstanding  all  this,  he  will  necessarily 
encounter  difficulties  in  his  eff"orts  to  subdue  it.  A  greater  length 
of  time  is  sometimes  required  than  the  patient  is  willing  to  give  ; 
and  the  opening  through  the  crown  to  the  central  cavity  is  fre- 
quently too  small,  previously  to  the  removal  of  the  partially  de- 
composed dentine,  to  admit  of  the  direct  application  of  the 
necessary  remedial  agent  to  the  inflamed  surface  of  the  pulp. 
Again,  it  often  happens,  that  the  situation  of  the  tooth  and  cavity 
are  such  as  to  prevent  a  complete  view  of  the  diseased  part.  It 
is  important  that  the  operator  should  get  such  a  view  to  enable 
him  to  determine  whether  the  inflamed  surface  is  ulcerated,  or 
pours  out  a  serous  fluid  ;  or  whether  the  morbid  condition  is 
simply  one  of  irritation,  produced  by  the  presence  of  acrid  matter, 
or  of  partially  or  wholly  decomposetl  dentine.  Unless  his  diag- 
nosis is  correct,  his  prescription  will  be  as  likely  to  do  harm  as 
good  :  but,  having  ascertained  the  exact  character  of  the  disease, 
he  may  often  be  able  to  institute  treatment  that  will  result  in  the 
restv^ration  of  the  pulp  and  the  preservation  of  the  tooth. 

It  is  important,  too,  to  understand  the  part  which  nature  plays 


432  INFLAMMATION    OF    THE    DENTAL    PULP. 

in  the  curative  process ;  for  cure  here,  as  in  other  parts  of  the 
body,  is  effected  by  that  internal  force,  which,  as  Chomel  says, 
"  presides  over  all  the  phenomena  of  life,  contends  unremittingly 
with  physical  and  chemical  laws,  receives  the  impression  of  dele- 
terious agents,  reacts  against  them  and  effects  the  resolution  of 
disease."  This  vital  force  is  sometimes  exercised  in  thf  cure  of 
disease  in  the  pulp  of  a  tooth,  but  more  frequently  in  its  pre- 
vention ;  as  is  shown  by  the  gradual  ossification  of  the  organ  in 
those  cases  where  it  would  otherwise  become  exposed  by  me- 
chanical or  spontaneous  abrasion  of  the  solid  structures  which 
enclose  it ;  and  occasionally  by  the  formation  of  secondary  den- 
tine upon  the  surface  of  the  original  or  primary  dentine  at  a 
point  toward  which  the  caries  is  advancing.  Nature,  no  doubt, 
would  always  provide  in  this  way  against  the  exposure  of  the 
pulp,  if  the  occurrence  were  always  long  enough  preceded  by 
sufficient  irritation  or  increase  of  vascular  action  in  it  to  call  her 
energies  into  operation.  But  the  formation  of  ostco-dentine, 
which  constitutes  the  protective  Avail  of  defence,  is  a  tardy  pro- 
cess, and  as  a  general  rule,  proceeds  more  slowly  than  the  caries 
in  the  tooth,  which  causes  the  exposure  of  the  pulp.  Besides,  it 
often  happens  that  its  approach  is  not  announced  by  the  slightest 
irritation,  a  condition  necessary  to  the  new  formation,  until  it 
reaches  the  central  cavity.  At  other  times,  the  approach  of  the 
disease  gives  rise  to  too  much  irritation,  a  condition  equally  un- 
favorable to  the  dentinification  of  the  pulp.  Thus,  no  protective 
covering  being  formed,  it  soon  becomes  exposed,  when  it  is  sub- 
jected to  the  action  of  such  irritating  agents  as  may  chance  to 
be  brought  into  contact  with  it.  Hence,  its  liability  to  become 
the  seat  of  chronic  inflammation  as  well  as  other  forms  of 
diseased  action. 

If  the  disease  is  attended  with  pain,  the  removal  of  this  must 
first  claim  attention,  and  should  be  effected  with  as  little  delay 
as  possible ;  otherwise  the  morbid  action  may  extend  to  every 
part  of  the  pulp  and  peridental  membrane,  and  assume  a  more 
active  and  unmanageable  form.  If  the  pain  is  the  result  of  irri- 
tation produced  by  the  direct  action  of  mechanical  or  chemical 
agents,  the  cavity  in  the  tooth  should  at  once  be  carefully  freed 
from  all  extraneous  substances  and  decomposed  portions  of  den- 
tine.    This  done,  a  dossil  of  raw  cotton  or  lint — saturated  with 


SPONTANEOUS    DISORGANIZATION    OF    DENTAL    PULP.         433 

spirits  of  camphor,  laudanum,  sulphuric  ether,  chloroform,  creo- 
sote, or  some  one  of  the  essential  oils — may  be  applitMl.  Imme- 
diate relief  is  sometimes  obtained  by  an  application  of  this  sort. 
Counter-irritants  have  sometimes  been  used  with  advantage. 
The  pain  has  often  been  removed  by  exciting  increased  secretion 
of  saliva,  but  when  a  sialagogue  is  used,  the  cavity  in  the  tooth 
should  be  filled  with  raw  cotton  or  lint  to  prevent  the  agent  from 
being  brought  in  contact  with  the  exposed  surface  of  the  pulp. 
But  a  remedy  which  will  relieve  the  pain  in  one  case  often 
aggravates  it  in  another. 

When  the  irritation  is  produced  by  acidulated  buccal  fluids, 
the  application  of  carbonate  of  soda  or  some  other  alkali,  will 
often  give  immediate  temporary  relief;  but  as  the  condition  of 
the  secretions  of  the  mouth,  especially  the  salivary,  is  usually 
owing  to  gastric  derangement,  the  correction  of  this  constitutes 
the  first  and  most  important  remedial  indication.  When  any 
application  is  made  to  the  pulp  for  the  purpose  of  removing  irri- 
tation and  pain,  its  full  effect  will  not  be  obtained  unless  the 
fluids  of  the  mouth  are  excluded  from  the  cavity  of  the  tooth; 
this  may  be  done  by  closing  the  orifice  with  softened  wax  or 
mastic,  using  the  precaution  not  to  force  it  in  so  far  as  to  press 
the  application  previously  made,  upon  the  exposed  pulp. 

Until  within  the  last  three  or  four  years,  the  writer  did  not 
believe  it  possible  to  preserve  the  vitality  of  a  tooth  by  filling, 
after  the  pulp  had  become  the  seat  of  chronic  inflammation,  but 
he  is  now  convinced  that  it  can  be  done  in  very  many  cases,  after 
a  proper  preparatory  treatment,  which  often  requires  several 
weeks. 

SPONTANEOUS  DISORGANIZATION. 

The  spontaneous  destruction  of  the  pulp  of  a  tooth  is  an  aff"ec- 
tion  which  seems  to  have  been  entirely  overlooked  by  writers  on 
dental  pathology;  and,  although  it  is  one  which  rarely  occurs, 
examples  of  it  are  met  with  sufficiently  often  to  entitle  it  to  a 
place  among  the  diseases  of  the  teeth.  The  first  case  which  at- 
tracted the  attention  of  the  author  occurred  in  1836,  and  he  has 
subsequently  met  with  six  or  seven  others.  In  each  of  them  the 
disorganization  had  been  carried  on  so  insidiously,  that  neither 


434         SPONTANEOUS    DISORGANIZATION    OF    DENTAL    PULP. 

the  presence  of  disease  nor  structural  alteration  was  suspected, 
until  the  teeth  had  assumed  a  dull  brownish  or  bluish -brown  ap- 
pearance. The  death  of  the  pulp  had  not  been  preceded  in  any 
of  these  cases  bj  the  slightest  indication  of  inflammatory  action. 
It  had,  apparently,  resulted  from  want  of  sufficient  vital  energy 
to  sustain  the  nutritive  function. 

The  sockets  of  the  affected  teeth,  in  these  cases,  were,  seem- 
ingly, in  a  healthy  condition — a  circumstance  which,  when  we 
take  into  consideration  that  the  parts  of  the  extremity  of  the 
roots  were  exposed  to  the  action  of  the  disorganized  remains  of 
the  dental  pulps,  may  appear  somewhat  strange  But  this  may 
have  been  owing,  partly,  to  diminished  excital)ility  in  the  alveolo- 
dental  periosteum,  and  partly  to  the  smallness  of  the  quantity, 
and  the  innocuous  character  of  the  matter  contained  in  the  cen- 
tral cavities  of  the  teeth.  The  gums  of  that  portion  of  the  al- 
veolar border  occupied  by  the  affected  teeth  had  a  pale,  grayish- 
purple  appearance,  but  exhibited  no  indications  of  actual  disease. 
They  were  as  thin  and  their  margins  as  distinctly  festooned  here 
as  in  any  other  part  of  the  mouth.  In  some  instances,  the  teeth 
had  been  in  this  condition  for  seven  or  eight  j'ears.  On  perfo- 
rating the  crowns,  only  a  drop  of  dark  brown  matter,  about  the 
consistence  of  thin  cream,  and  having  but  little  odor,  escaped 
from  the  pulp-cavity  of  each. 

In  all  the  cases  which  the  author  has  seen  of  this  remarkable 
affection,  the  loss  of  vitality  had  taken  place  previously  to  the 
twentieth  year  of  age,  and,  according  to  his  observations  upon 
the  subject,  it  seldom  confines  itself  to  a  single  tooth,  but  occurs 
simultaneously  in  corresponding  teeth.  The  pulps  of  several 
usually  perish  at  about  the  same  time.  In  the  first  case  to  which 
his  attention  was  called,  six  had  lost  their  vitality.  The  affec- 
tion, too,  seems  to  be  principally  confined  to  the  incisors  and 
cuspids,  and  sound  teeth  appear  to  be  as  subject  to  it  as  those 
which  are  carious. 

Now,  as  the  disorganization  of  the  pulp,  in  cases  of  this  sort, 
is  not  the  result  of  inflammatory  action,  it  must  be  dependent 
upon  constitutional  rather  than  local  causes — upon  some  peculiar 
cachexia,  which  causes  the  function  of  sanguinification  to  be  im- 
perfectly performed.  This  inference,  too,  seems  to  be  fully 
warranted  by  the  appearance  of  the  subjects  in  all  the  cases 


FUNGOUS  GROWTH  OF  THE  DENTAL  PULP.       435 

which  the  author  has  had  an  opportunity  of  examining — charac- 
terized by  an  extremely  pale  and  slightly  bloated  aspect  of  coun- 
tenance, indicating  a  serous  condition  of  blood. 

The  remedial  indications  in  cases  of  this  sort  are  the  same  as 
in  necrosis  produced  by  inflammation  and  suppuration  of  the 
lining  membrane  and  pulp. 

FUNGOUS  GROWTH. 

The  pulp  of  a  tooth,  when  exposed  by  decay  of  the  crown, 
sometimes  becomes  the  seat  of  a  fungous  growth,  in  the  form  of 
a  small  vascular  tumor.  These  morbid  growths  sometimes  attain 
the  size  of  a  large  pea,  completely  filling  the  cavity  made  in  the 
crown  of  the  tooth  by  decay ;  at  other  times  they  do  not  exceed 
that  of  a  small  elderberry.  The  former  have  little  sensibility, 
and  bleed  freely  from  the  slightest  injury;  the  latter  are  less 
vascular,  but  are  nearly  as  sensitive  as  the  pulp  in  a  healthy 
state. 

It  often  happens  that  a  fungous  growth  of  the  gum  or  dental 
periosteum,  finding  its  way  through  an  opening  in  the  side  of  the 
neck  or  root  of  a  decayed  tooth,  appears  in  the  central  cavity, 
and  is  sometimes  mistaken  for  a  morbid  growth  of  the  pulp. 
Such  tumors  usually  grow  very  fast,  and  sometimes  attain  the 
size  of  a  hickory  nut.  They  are  exceedingly  vascular,  bleeding 
profusely  when  Avounded,  and  are  soon  reproduced  after  removal. 
The  author  has  met  with  tumors  of  this  kind  which  had  origi- 
nated in  the  alveolo-dental  periosteum  of  the  extremity  of  the 
root. 

The  only  remedy  in  such  cases  is  the  removal  of  the  tooth. 
A  cure  cannot  be  effected  by  extii'pating  the  morbid  growth. 
The  author  has  frequently  removed  them  nearly  to  the  extremity 
of  the  root,  but  they  have  always  reappeared  in  a  few  days  or 
weeks  after  the  operation.  Even  if  a  return  of  the  disease  could 
be  prevented,  the  extraction  of  the  tooth  should  be  insisted  on, 
as  all  teeth  in  which  tumors  of  this  sort  are  situated,  are  morbid 
irritants,  and  cannot  remain  without  detriment  to  the  health  of 
the  parts  with  which  they  are  in  immediate  connection. 


436  OSSIFICATION    OF    THE    DENTAL    PULP. 


OSSIFICATION, 

Allusion  has  been  made,  several  times,  in  the  course  of  this 
work,  to  the  ossification  of  the  dental  pulp,  as  a  means  employed 
by  nature  to  prevent  the  exposure  of  this  most  delicate  and 
exquisitely  sensitive  structure.  But  examples  of  it  are  occasion- 
ally met  with  in  teeth  which  have  suifered  no  loss  of  substance, 
either  from  mechanical  or  spontaneous  abrasion,  or  from  the 
decay  of  the  dentine.  The  occurrence,  whatever  may  be  the 
circumstances  under  which  it  takes  place,  is  evidently  the  result 
of  the  operation  of  an  established  law  of  the  economy,  dependent 
upon  moderate  irritation  and  a  slight  increase  of  vascular  action  : 
ossification  having  commenced,  it  usually  goes  on  until  every 
part  of  the  pulp  is  converted  into  a  substance  analogous  to 
cementum.  We  infer,  then,  that  when  the  pulp  of  a  tooth  be- 
comes the  seat  of  a  sufficient  amount  of  irritation,  ossification 
must  follow  as  a  necessary  consequence ;  but  if  the  irritation  be 
succeeded  by  active  inflammation,  a  difi'erent  result  may  be 
expected. 

The  irritation  necessary  for  the  ossification  of  the  pulp  of 
a  tooth  sometimes  arises  from  constitutional  causes;  but  in  the 
majority  of  cases,  it  results  from  the  action  of  local  irritants, 
and  most  frequently  from  impression  of  heat  and  cold,  commu- 
nicated through  the  medium  of  a  metallic  filling  or  a  thin  layer 
of  dentine. 

During  the  ossification,  a  sensation  is  occasionally  experienced 
in  the  tooth  somewhat  similar,  though  altogether  less  in  degree, 
to  that  which  attends  the  knitting  of  the  fractured  extremities 
of  a  broken  bone.  A  numb,  vibratory  pain,  barely  perceptible, 
is  felt  passing  through  the  tooth  several  times  a  day,  but  only 
lasting  a  second  or  two  at  a  time.  It  is  scarcely  sufficient  to 
occasion  any  annoyance,  or  to  attract  anything  more  than  mo- 
mentary attention. 

With  the  ossification  of  the  pulp,  the  crown  and  inner  walls 
of  the  root  lose  their  vitality,  but  the  appearance  of  the  tooth  is 
not,  as  in  the  case  of  necrosis  arising  from  the  disorganization  of 
the  pulp,  materially  affected.  The  central  cavity  being  filled 
with  semi-translucent  osteo-dentine,  the  crown  retains  its  natural 


INFLAMMATION    OF    THE    DENTAL    PERIOSTEUM.  437 

color.  The  discoloration  and  opacity  attending  necrosis  pro- 
duced by  other  causes,  result,  partly  from  the  presence  of  putrid 
matter  in  the  pulp-cavity,  and  partly  from  its  absorption  by  the 
surrounding  dentinal  walls. 


INFLAMMATION  OF  THE  DENTAL  PERIOSTEUM. 

Inflammation  of  the  periosteum  of  a  tooth  may  be  acute  or 
chronic^  each  variety  being  modified  in  its  character  both  by  the 
state  of  the  constitutional  health  and  by  the  causes  concerned 
in  its  production.  The  acute  variety,  when  left  to  itself,  usually 
terminates  in  alveolar  abscess,  the  suppurative  process  sometimes 
extending  to  nearly  every  part  of  the  periosteum,  causing  the 
entire  death  of  a  tooth,  and  often  followed  by  erosion  of  the 
root,  and  necrosis  of  the  alveolus.  When  favored  by  a  cachectic 
habit  of  body,  it  often  extends  to  the  periosteum  of  the  jaw, 
followed  by  suppuration  and  necrosis.  The  following  case  will 
give  some  idea  of  the  severity  which  it  occasionally  assumes. 

In  1840,  a  poor  girl,  aged  fourteen,  was  brought  to  the  author. 
About  three  months  before,  she  had  been  taken  to  a  barber  tooth- 
drawer  for  the  purpose  of  having  the  first  left  inferior  molar  ex- 
tracted. The  crown  was  broken  off",  the  roots  left  in  the  socket. 
Inflammation  supervened.  This  soon  extended  to  the  periosteum 
of  the  entire  bone  from  the  second  bicuspid  to  the  coronoid  process ; 
as  it  was  permitted  to  run  its 
course  uninterruptedly,  it  ter- 
minated in  necrosis  and  ex- 
foliation of  all  this  portion  of 
the  bone  (Fig.  156),  the  an- 
terior extremity  of  which, 
when  first  seen  by  the  author, 
had  passed  through  the  in- 
teguments of  the  lower  part 
of  the  face,  and  protruded 
externally.     A  few  days  after,  it  was  removed  without  difficulty. 

As  the  causes,  symptoms  and  remedial  indications  of  acute 
inflammation  of  the  dental  periosteum  were  briefly  described  in 
the  chapter  on  tooth-ache,  and  as  we  shall  have  occasion  to  refer 
to  the  subject  again  when  we  come  to  treat  of  alveolar  abscess. 


438  INFLAMMATION    OF    THE    DENTAL    PERIOSTEUM, 

it  will  not  be  necessary  to  dwell  upon  it  here.  We  shall  merely 
state,  however,  that,  after  having  terminated  in  suppuration,  it 
sometimes,  instead  of  subsiding  altogether,  degenerates  into  a 
chronic  form,  and  when  favored  by  some  constitutional  vice,  as 
the  scorbutic,  venereal,  or  scrofulous,  it  often  gives  rise  to  the 
destruction  of  the  socket  and  loss  of  the  tooth. 

Chronic  inflammation  of  the  dental  periosteum,  is  not  always 
preceded  by  the  active  form  of  the  disease,  but  may  assume  this 
form  at  the  commencement.  In  this  case  it  is  complicated  with 
tumefaction  of  the  gums,  and  discharge  of  puriform  matter  from 
between  their  edges  and  the  necks  of  the  teeth.  For  the  treat- 
ment of  this  variety,  the  reader  is  referred  to  chronic  inflamma- 
tion and  tumefaction  of  the  gums. 


CHAPTER    TWENTY-FIRST. 

DISLOCATIOX  OF  THE  LOWER  JAW. 

From  the  peculiar  manner  in  which  the  inferior  maxilla  is 
articulated  to  the  temporal  bones,  it  is  not  very  liable  to  disloca- 
tion. When  it  occurs  in  one  or  both  of  the  condyles,  the  luxa- 
tion is  always  forward :  the  conformation  of  the  parts  preventing 
it  from  taking  place  in  any  other  direction.  The  oblong,  rounded 
head  of  each  condyle  is  received  into  the  fore  part  of  a  deep 
fossa  in  the  temporal  bone,  situated  just  before  the  meatus  audi- 
torius  externus,  and  under  the  beginning  of  the  zygomatic  arch. 
The  articular  surface  of  each  is  covered  with  a  smooth  cartilage, 
and  between  them  there  is  a  movable  cartilage.  This  latter  is 
connected  with  the  articulating  surfaces  of  the  condyle  and 
glenoid  cavity,  externally  by  the  external  lateral  ligament,  in- 
ternally by  the  capsular  ligament,  and  in  front  by  the  tendon  of 
the  external  pterygoid.  This  cartilage  is  sometimes  called  the 
meniscus,  from  its  shape,  being  thickest  around  its  circumference, 
especially  at  the  back  part.  The  temporo-maxillary  articulation 
is  strengthened  by  an  internal,  an  external  and  a  capsular  liga- 
ment :  also  by  the  tendinous  and  muscular  insertions  of  the  mas- 
seter,  temporal  and  pterygoid  muscles.  The  intervening  movable 
cartilage,  being  more  closely  connected  with  the  head  of  the 
condyle  than  with  the  glenoid  cavity,  escapes  with  the  former, 
whenever  dislocation  of  the  jaw  takes  place. 

Dislocation  of  the  lower  jaw  is  rarely  caused  by  a  blow,  unless 
given  when  the  mouth  is  open ;  it  is  more  frequently  occasioned 
by  yawning  or  laughing.  It  has  been  known  to  occur  in  the  ex- 
traction of  teeth,  and  in  attempting  to  bite  a  very  large  sub- 
stance. Sir  Astley  Cooper  mentions  the  case  of  a  boy  who  had 
his  jaw  dislocated  by  suddenly  putting  an  apple  into  his  mouth 
to  keep  it  from  a  playfellow. 

After  the  jaw  has  been  dislocated  once,  it  is  always  more  liable 
to  this  accident ;  consequently  Mr.  Fox  very  properly  recommends 


440 


DISLOCATION    OF    THE    LOWER    JAW. 


to  those  with  whom  it  has  once  happened,  the  precaution  of  sup- 
porting the  jaw  whenever  the  mouth  is  opened  very  widely  in 
gaping,  or  for  the  purpose  of  having  a  tooth  extracted.  None 
of  these  causes  would  be  sufificient  to  produce  the  accident,  unless 
the  ligaments  of  the  temporo-maxillary  articulation  are  very 
loose,  and  the  muscles  of  the  jaw  much  relaxed. 

The  author  witnessed  a  case  of  dislocation  of  the  lower  jaw  in 
which  the  displacement  occurred  during  an  attempt  to  extract 
the  first  right  inferior  molar.  The  patient  was  a  young  lady  from 
Virginia,  about  seventeen  years  of  age.  Both  condyles  were 
luxated,  but  so  completely  were  the  muscles  of  the  jaw  relaxed, 
that  he  immediately  reduced  it  without  the  least  difficulty;  and 
afterward,  by  supporting  the  jaw  with  his  left  hand,  succeeded 
in  removing  the  tooth. 

When   the   lower  jaw  is  dislocated,  the  mouth  remains  wide 

open,  as  seen  in  Fis;.  157,  and 
Fig.   157.  ^      '  ^  .       . 

a  great  deal  of  pain  is  ex- 
perienced ;  this,  according  to 
Boyer,  is  caused  by  the  pres- 
sure of  the  condyles  on  the 
deep-seated  temporal  nerves, 
and  those  which  go  to  the 
masseter  muscles,  situated  at 
the  root  of  the  zygomatic  pro- 
cess. The  condyles,  having 
left  their  place  of  articulation, 
are  advanced  before  the  articu- 
lar eminences  and  lodged  under 
the  zygomatic  arches.  The  jaw 
cannot  be  closed  ;  the  coronoid 
processes  may  be  felt  under  the  malar  bones;  the  temporal, 
masseter  and  buccinator  muscles  are  extended ;  the  articular 
cavities  being  empty,  a  hollow  may  be  felt  there;  the  saliva 
flows  uninterruptedly  from  the  mouth,  and  deglutition  and  speech 
are  either  wholly  prevented,  or  very  greatly  impaired.  Boyer 
says,  that  during  the  first  five  days  after  the  accident,  the  patient 
can  neither  speak  nor  swallow.  The  jaw,  when  only  one  condyle 
is  displaced,  is  forced,  more  or  less,  to  one  side. 

If  the  dislocation  continues  for  several   days  or  weeks,  the 


DISLOCATION    OF    THE    LOAVER    JAW.  441 

chin  gradually  approaches  the  upper  jaw,  and  the  patient  slowly 
recovers  the  functions  of  speech  and  deglutition.  We  are  told 
by  Mr.  Samuel  Cooper,  that  it  may  prove  fatal  if  it  remain  un- 
reduced ;*  but  Sir  Astley  Cooper  says,  he  has  never  known  any 
dangerous  effects  to  result  from  this  accident ;  on  the  contrary, 
after  it  has  continued  for  a  considerable  length  of  time,  the  jaw 
partially  recovers  its  motion,  f 

In  the  reduction  of  dislocation  of  the  lower  jaw,  the  older 
surgeons  employed  two  pieces  of  wood,  which  were  introduced  on 
each  side  of  the  mouth,  between  the  molar  teeth ;  while  these 
were  made  to  act  as  levers  for  depressing  the  back  part  of  the 
bone,  the  chin  was  raised  by  means  of  a  bandage. 

The  method  usually  adopted  by  modern  surgeons  for  reducing 
a  dislocation  of  this  bone,  consists  in  introducing  the  thumbs, 
wrapped  in  a  napkin  or  cloth,  (to  prevent  them  from  being  hurt 
by  the  teeth,)  as  far  back  upon  the  molars  as  possible ;  then  de- 
pressing the  back  part  of  the  jaw,  and  at  the  same  time,  raising 
the  chin  with  the  fingers.  In  this  way  the  condyles  are  disen- 
gaged from  under  the  zygomatic  arches,  and  made  to  glide  back 
into  their  articular  cavities.  But  the  moment  the  condyles  are 
disengaged,  the  thumbs  of  the  operator  should  be  slipped  outward 
between  the  teeth  and  the  cheeks ;  as  the  action  of  the  muscles, 
at  this  instant,  in  drawing  the  jaw  back,  causes  it  to  close  very 
suddenly,  and  with  considerable  force.  This  precaution  is  neces- 
sary to  avoid  being  hurt,  unless  a  piece  of  cork  or  soft  wood  has 
been  previously  placed  between  the  teeth. 

By  the  foregoing  simple  method  the  dislocation  may,  in  almost 
every  case,  be  readily  reduced  ;  but  Mr.  Fox  mentions  a  case  in 
which  it  failed.  The  subject  was  a  lady  whose  lower  jaw  had 
been  luxated  several  times  before ;  this  time  the  accident  was 
occasioned  by  an  attempt  which  he  made  lo  extract  one  of  the 
inferior  dentes  sapientiae.  After  having  failed  to  reduce  the 
luxated  bone  by  the  usual  method,  he  "  happened  to  recollect  a 
statement  made  to  him  by  M.  de  Cheraant,  who  having  been 
frequently  applied  to  by  a  person  in  Paris  who  was  subject  to 
this  accident,  had  always  succeeded  in  immediately  reducing 
the  luxation,  by  means  of  a  lever  of  wood,  as  recommended  by 

*  Surgical  Dictiouary,  p.  306. 

f  A.  Cooper  on  Dislocations,  p.  389. 

29 


442  DISLOCATION    OF   THE    LOWER   JAW. 

Dr.  Monroe."  Profiting  by  this  statement,  Mr.  Fox  procured  a 
piece  of  wood  about  an  inch  square,  and  ten  or  twelve  inches 
long.  He  placed  one  end  of  this  upon  the  lower  molars,  and 
then  raised  the  other,  so  that  the  upper  teeth  acted  as  a  fulcrum. 
As  soon  as  the  jaw  was  depressed,  the  condyle  of  the  side  upon 
which  the  wood  was  applied,  immediately  slipped  back  into  its 
articular  cavity.  The  wood  was  then  applied  to  the  opposite 
side  of  the  jaw,  and  the  other  condyle  reduced  in  the  same 
manner.* 

The  method  proposed  by  Sir  Astley  Cooper,  consists,  when 
both  condyles  are  displaced,  in  introducing  two  corks  behind  the 
molars,  and  then  elevating  the  chin.  He,  hoAvever,  first  places 
his  patient  in  a  recumbent  posture  ;t  but  this  is  seldom  necessary. 
The  reduction  of  the  dislocation  can  be  as  conveniently  effected 
with  the  patient  in  a  sitting  as  in  a  recumbent  posture. 

After  the  reduction  of  the  dislocation,  the  patient  is  recom- 
mended to  abstain  for  several  days  from  the  use  of  solid  aliments, 
and  to  wear  a  four-tailed  bandage  ;|  or,  what  is  still'  better,  the 
bandage  contrived  by  Mr.  Fox,  (Fig.  74)  to  prevent  its  recurrence 
in  the  extraction  of  teeth.  When  this  bandage  is  used  for  the 
latter  purpose,  the  mouth  is  first  opened  to  the  proper  extent,  with 
the  condyles  in  their  articular  cavities  ;  it  is  then  applied,  and 
the  straps  tightly  buckled.  This  done,  it  is  impossible  to  advance 
the  jaw  sufficiently  to  produce  a  dislocation. 

*  American  edition  of  Fox  on  the  Human  Teeth,  p.  330. 
f  A.  Cooper  on  Dislocations,  p.  391. 
J  Cooper's  Surgical  Dictionary,  p.  306. 


\ 


PART    FOURTH. 


SALIVARY  CALCULUS. 


DISEASES  OF  THE   GUMS   AND   ALVEOLAR 
PROCESSES,  AND  THEIR  TREATMENT. 


I 


PART   FOURTH. 


CHAPTER    FIRST. 
SALIVARY  CALCULUS. 

The  physical  characteristics,  and  the  local  and  constitutional 
indications  of  salivary  calculus,  having  been  noticed  in  a  pre- 
ceding chapter,  it  will  not  be  necessary  to  refer  to  them  again. 
We  shall,  therefore,  confine  our  remarks  chiefly  to  its  elementary 
constituents,  its  origin,  the  manner  of  its  formation,  its  eflFects, 
and  the  removal  of  it  from  the  teeth. 

Tartar  or  salivary  calculus  sometimes  accumulates  in  very 

FiQ.   158.  Fig.  159. 


large  quantities,  giving  to  the  mouth  a  most  disagreeable  and 
repulsive  aspect,  and  imparting  to  the  breath,  not  unfrequently, 
an  almost  insufferably  offensive  odor.  Fig.  158  represents  a  set 
of  teeth  encrusted  with  it,  and  Fig.  159  a  single  tooth,  presented 
to  the  author  by  Dr.  W.  Allen,  of  Massachusetts,  with  the 
largest  accumulation  of  this  substance  he  has  ever  seen  in  one 
mass.  Its  longest  diameter  is  an  inch  and  an  eighth,  its  shortest 
seven-eighths,  and  its  thickness  five-eigliths  of  an  inch.  Im- 
bedded in  its  substance  is  the  entire  crown  and  neck  of  a  lower 
dens  sapientige,  which  was  removed  with  it.  It  is  of  a  light  brown 
color,  and  weighs  two  drachms  and  seventeen  grains. 


446        CHEMICAL    CONSTITUENTS    OF    SALIVARY    CALCULUS. 

Professor  Austen  describes  a  remarkable  case  where  every 
tooth  above  and  below  had  been  loosened  by  alveolar  absorption 
caused  by  this  deposit ;  no  tooth  having  more  than  an  eighth  of 
an  inch  depth  of  socket,  and  some  of  them  held  only  by  an  ex- 
ceedingly tough  attachment  to  the  gum  and  periosteum.  The 
tartar  upon  the  lower  incisors  was  equal  to  five  times  the  size  of 
the  teeth  ;  most  of  it  being  on  the  inside  and  three-quarters  of 
an  inch  thick  at  the  base.  A  singular  peculiarity  in  this  case 
was  the  excessive  pain  of  extraction.  Small  as  was  the  attach- 
ment, it  was  uncommonly  firm ;  and  the  patient,  a  working  man, 
was  laid  up  with  nervous  prostration  for  two  weeks  after  the 
operation. 

CHEMICAL  CONSTITUENTS  OF  SALIVARY  CALCULUS. 

Salivary  calculus  is  composed  of  phosphate  of  lime  and  animal 
matter,  combined  in  various  proportions,  accordingly  as  it  is 
hard  or  soft ;  consequently  no  two  analyses  will  yield  the  same 
result.  The  following  is  the  analysis  made  by  Mr.  Peps  for  Mr. 
Fox.     Fifty  parts  yielded  : 

Phosphate  of  lime,  .....  35 
Fibrin,  or  cartilage,  .....  9 
Animal  fat,  or  oil,      .  .  .  .  .3 

Loss,         .......         3 

50 

Berzelius  gives  the  following  analysis.  He  found  one  hundred 
parts  to  contain 

Phosphate  of  lime  and  magnesia,       .  .     79.0 

Salivary  mucus  and  salivine,      .  .  •     13.5 

Animal  matter,         .         .         .         .         .7.5 


100.0 

Dr.  Dwindle,  of  New  York,  furnishes  the  following : 

Phosphate  of  lime,  .  .  .  .  .60 
Carbonate  of  lime,  .....  14 
Animal  matter  and  mucus,  .          .          .16 

Water  and  loss,  .          .         .          .          .10 

100 


ORIGIN    AND    DEPOSITION    OF    SALIVARY    CALCULUS.         447 

The  last  named  gentleman  acknowledges  that  he  could  make 
no  two  analyses  agree.  Hard  dry  tartar  contains  more  earthy 
and  less  animal  matter  than  the  soft  humid  tartar. 

The  infusoria  of  which  M.  Mandl  says  tartar  is  composed, 
have  their  origin  in  the  vitiated  mucus  which  is  always  mixed 
with  it.  Scherer  detected  with  a  microscope  in  large  numbers, 
infusoria,  in  the  saliva  of  a  girl  laboring  under  a  scorbutic  affec- 
tion of  the  mouth  ;  but  the  author  is  inclined  to  believe  that  they 
had  their  origin  in  the  mucous  secretions  of  this  cavity,  which 
are  always  mixed  with  the  former  fluid.  They  are  more  or  less 
numerous,  as  the  tartar  is  hard  or  soft,  or  in  proportion  to  the 
quantity  of  mucus  that  enters  into  its  composition.* 

ORIGIN  AND  DEPOSITION  OF   SALIVARY  CALCULUS. 

There  exists  much  diversity  of  opinion  as  to  the  source  from 
whence  salivary  calculus  is  derived.  English  and  American 
writers  believe  it  to  be  a  deposit  from  the  saliva,  but  the  French 
do  not  agree  concerning  its  origin.  Jourdain  thinks. it  is  secreted 
by  glands,  which  he  believes  to  be  scattered  over  the  periosteum 
of  the  teeth.  Gariot  says  it  comes  from  the  gums.  Serres  tells 
us  he  has  discovered  upon  the  mucous  membrane  of  the  gums, 
certain  glands,  whose  particular  function  it  is  to  secrete  this  sub- 
stance. In  commenting  upon  the  views  of  this  last  mentioned 
author,  M.  Delabarre  remarks  :  "  The  small  dental  glands,"  as  he 
calls  them,  "  perhaps  belong  to  the  mucous  or  salivary  system ; 
for  the  saliva,  as  all  physiologists  know,  is  not  furnished  by  the 
parotid  and  other  larger  glands  alone,  but  by  a  great  number  of 
small  glands  that  are  very  observable  in  ruminating  animals, 
scattered  over  various  parts  of  the  mucous  membrane  of  the  mouth. 
I,  therefore,  am  of  opinion  that  this  is  a  gratuitous  supposition 
on  the  part  of  the  author ;  because  children  of  a  very  early  age 
are  not  affected  with  tartar,  and  it  is  on  them  that  he  believes  he 
has  discovered  the  glands  which  produce  it.  Did  these  really 
exist,  they  would  augment  instead  of  decreasing  in  size,  as  age 
advanced;  and  their  functions  becoming  more  and  more  establish- 
ed, they  would  attain  to  a  very  large  size  in  old  persons  and  those 

*"  Dr.  Dwindle  gives  a  minute  description  of  their  appearance  in  the  1st  No.  of  the 
5th  volume  of  the  American  Journal  of  Dental  Science. 


448         ORIGIN    AND    DEPOSITION    OF    SALIVARY    CALCULUS. 

most  subject  to  tartar.  Now,  there  is  nothing  to  lead  one  to 
infer  their  existence  in  these  individuals.  Therefore,  to  suppose 
that  organs,  which  may  be  very  perceptible  before  their  function 
begins,  cannot  be  discovered  when  their  secretion  is  fully 
established,  is  contrary  to  sound  philosophy  ;  in  this  case,  the 
dental  glands  of  the  author  would  be  entirely  different  from  all 
others,  which  are  the  more  distinct  in  proportion  as  they  are 
more  active.  Inadmissible,  then,  as  this  supposition  is,  I  do  not 
believe  in  the  existence  of  these  glands,  which  I  have  patiently 
but  in  vain  searched  for." 

Mons.  Serres  referred  probably  to  the  small  glands  lying 
under  the  mucous  membrane,  which  have  no  more  special  action 
in  the  deposition  of  calculus  than  any  other  of  the  salivary 
glands.  The  largest  are  about  the  size  of  a  small  pea,  and  have 
been  termed,  according  to  their  situation,  the  labial^  buccal  and 
molar  glands. 

But  M.  Delabarre  is  not  more  fortunate  in  the  theor}^  Avhich 
he  advances  of  the  origin  of  salivary  calculus,  than  Serres.  He 
believes  it  to  be  an  exhalation  from  the  mucous  membrane  of  the 
gums.  Alluding  to  what  M.  Dupuy,  professor  of  the  veterinary 
establishment  at  Alfont,  says,  concerning  the  formation  of  cal- 
careous tubercle  in  soft  tissues,  where  he  supposes  there  are  no 
other  fluids  but  mucus ;  he  tells  us  that  it  is  "  in  the  same  man- 
ner that  the  exhalants  of  the  gums  furnish  tartar,  which  they 
give  out  more  or  less  accordingly  as  the  gums  are  in  a  healthy 
or  inflamed  state.  When  diseased,  they  are  covered  with  a 
whitish  layer,  which  is  at  first  soft,  but  gradually  collecting  upon 
the  teeth,  it  afterward  becomes  hard."  According  to  this 
author,  it  is  only  when  the  gums  are  inflamed  that  tartar  is  pro- 
duced. 

In  this  way  he  accounts  for  its  accumulation  on  the  teeth  of 
one  side  of  the  mouth,  while  those  of  the  other  have  none  of  it 
on  them,  though  they  are  all  alike  bathed  in  the  saliva.  The 
concretion  of  earthy  salts  in  the  salivary  ducts,  he  accounts  for 
by  supposing  it  to  be  deposited  by  the  exhalants  of  the  mucous 
membrane  which  lines  them,  and  not  from  the  fluid  they  convey 
to  the  mouth. 

He  accounts  for  analogous  formations  in  other  parts,  in  the 
same  way.     The  calculous  incrustation  upon  a  sound,  which  has 


ORIGIN    AND    DEPOSITION    OF    SALIVARY    CALCULUS.         449 

remained  in  the  bladder  for  a  long  time,  and  which  is  found  in 
cases  where  no  previous  disposition  to  gravel  had  existed,  he 
supposes  to  result  from  irritation  excited  by  the  instrument  in 
the  mucous  membrane  of  this  viscus.  In  replying  to  this  part 
of  his  argument,  Mr.  Bell  says:  "The  previous  non-existence 
of  calculus  in  the  bladder  cannot  be  deemed  any  proof  that  the 
elements  of  its  composition  had  not  been  held  in  solution  in  the 
urine  ;  requiring  only  the  occurrence  of  any  extraneous  body  in 
the  bladder  to  serve  as  a  nucleus  for  its  deposition.  This  view 
of  the  subject  is  amply  confirmed  by  the  fact,  that  depositions, 
both  of  the  lithic  salts  and  of  the  triple  phosphate,  the  bases 
of  the  usual  varieties  of  urinary  calculi,  are  constantly  formed 
from  the  urine,  after  its  expulsion  from  the  bladder." 

It  is  unfortunate  for  M,  Delabarre  that  he  drew  this  analogy, 
for  Mr.  Bell  has  shown  it  to  be  conclusive  against  the  theory 
which  he  intended  to  establish  by  it.  He  says  ;  "  that  salivary 
calculus,  or  tartar  of  the  mouth,  is  deposited  in  a  similar  manner 
from  the  saliva,  is,  I  think,  directly  proved ;  or  is  at  least  sup- 
ported in  the  highest  degree  of  probability  by  every  circumstance 
connected  with  its  formation."  The  fact,  too,  that  it  is  always 
found  in  largest  quantity  on  the  teeth  opposite  the  mouths  of 
the  salivary  ducts,  is  of  itself  a  strong  argument  in  favor  of  this 
theory;  but  still  more  conclusive  is  the  fact  of  its  formation 
within  the  very  ducts  themselves. 

The  theory  of  M.  Delabarre  is  insufficient  for  the  explanation 
of  its  deposition  here;  for  it  is  not  presumable  that  inflamma- 
tion would  seize  upon  a  single  point  of  the  mucous  membrane 
of  one  of  these  passages,  without  affecting  it  to  a  considerable 
extent.  The  most  probable  cause  of  its  formation  here,  as  it 
appears  to  us,  is  the  accidental  precipitation  of  a  particle  of  it 
from  the  saliva  in  its  passage  to  the  mouth;  Avhich  particle, 
becoming  entangled  in  the  mucus,  is  detained,  and  afterwards 
serves  as  a  nucleus  for  subsequent  deposition. 

Of  the  existence  of  the  elements  of  the  composition  of  calcu- 
lus in  the  saliva  there  can  be  no  question.  Chemical  analyses 
of  this  fluid,  direct  from  the  glands,  place  all  doubt  upon  the 
subject  at  rest.  Turner,  in  enumerating  the  chemical  consti- 
tuents of  saliva,  mentions  bone  earth  as  one;*  and  Tiedemann, 

«  Turner's  Chemistry,  p.  756. 


450        ORIGIN    AND    DEPOSITION    OF    SALIVARY    CALCULUS. 

Gmelin,*  and  Scherer,t  have  detected  phosphate  of  lime;  as 
has  also  Enderliu,|  and  other  chemists  who  have  analyzed  this 
fluid.  Thus  it  is  seen  that  the  chief  earthy  constituents  which 
enter  into  the  formation  of  this  substance  are  contained  in  the 
saliva.  It  may  also  exist  in  solution  in  the  raucous  fluid  of  the 
mouth. 

M.  Delabarre  seems  to  rely  upon  the  circumstance,  that  its 
deposition  on  the  teeth  is  always  accompanied  by  inflammation 
of  the  gums,  as  conclusive  in  favor  of  the  correctness  of  his 
views  of  its  formation.  But  here,  again,  he  is  equally  unfortu- 
nate ;  for  the  inflammation  of  which  he  speaks  is  the  eff"ect,  and 
not,  as  he  supposes,  the  cause,  of  its  deposition.  The  soft, 
white  layer  of  tartar,  of  which  he  makes  mention,  as  observable 
on  the  gums  when  diseased,  is  nothing  more  than  thick,  hardened 
mucus.  We  have  repeatedly  examined  it,  and  are  well  assured 
of  the  correctness  of  this  assertion. 

That  the  deposition  of  tartar  may  take  place  on  one  side  of 
the  mouth,  without  a  similar  deposit  on  the  opposite  side,  fur- 
nishes no  evidence  in  support  of  the  doctrine  that  it  is  an  exha- 
lation from  the  capillaries  of  the  mucous  membrane  of  the  gums. 
The  mastication  of  food  is,  with  most  persons,  performed  more 
on  one  side  of  the  mouth  than  on  the  other;  that  this  function 
prevents,  in  a  great  degree,  the  accumulation  of  tartar  on  the 
organs  immediately  concerned,  is  a  fact  with  which  every  den- 
tist must  be  familiar.  Hence,  its  frequent  collection  on  the 
teeth  of  one  side,  and  not  on  those  of  the  other.  And  that  it 
is  ascribable  to  this  circumstance,  is  susceptible  of  positive  proof. 
If,  on  the  removal  of  the  tartar  from  the  teeth  of  a  person,  in 
whose  mouth  it  has  collected  only  on  those  of  one  side,  mastica- 
tion be  afterwards  altogether  performed  on  this  side,  it  will  not 
re-accumulate  on  them  ;  and  if  requisite  attention  to  the  clean- 
liness of  the  teeth  on  the  other  side  be  not  observed,  it  will  soon 
collect  there,  although  these  teeth  had  before  remained  free 
from  it. 

Again,  it  often  happens  that  disease  of  a  severe  character  is 
excited  in  the  gums  by  the  use  of  mercurial  medicines  and  other 
causes,  and  yet  but  a  small  quantity  of  tartar  collects  on  the 

*  Muller's  Physiology,  voL  i,  p.  461.  f  French  Lancet,     April,  1845. 

J  Liebig,  Annalen,  1844,  pp.  3  and  4. 


EFFECTS    OF   SALIVARY    CALCULUS.  451 

teeth;  but  that  any  condition  of  the  general  system,  or  of  the 
mouth,  tending  to  make  the  fluids  of  this  ca'Vity  more  viscid,  pro- 
motes its  formation,  is  undeniable.  There  are,  however,  some 
temperaments  much  more  favorable  to  its  production  than  others ; 
and  it  is  a  well-established  fact,  that  the  mucous  membrane  of 
those  in  whose  mouths  it  accumulates  in  largest  quantity  is  the 
most  irritable,  and  the  buccal  fluids  most  viscid.  Again,  if  it 
were  deposited  by  the  mucous  fluids  of  the  mouth,  it  would  col- 
lect in  largest  quantities  on  those  teeth  which  are  less  abund- 
antly bathed  in  the  saliva;  as,  for  example,  the  anterior  surfaces 
of  the  upper  incisors  and  cuspids,  while  those  opposite  to  the 
mouths  of  the  ducts,  which  discharge  this  fluid  into  the  mouth, 
would  be  less  liable  to  deposits  of  tartar  than  any  of  the  other 
teeth;  whereas  the  contrary  is  found  to  be  the  case. 

From  all  the  light,  therefore,  that  has  been  thrown  upon  this 
subject,  the  conclusion  appears  to  us  irresistible,  that  this  earthy 
matter  is  chiefly  a  salivary  deposit,  and  takes  place  in  the  fol- 
lowing manner:  It  is  precipitated  from  the  saliva,  as  this  fluid 
enters  the  mouth,  upon  the  surfaces  of  the  teeth,  opposite  the 
openings  into  the  ducts,  from  which  it  is  poured.  To  these  its 
particles  become  agglutinated  by  the  mucus  always  found,  in 
greater  or  less  quantity,  upon  them.  Particle  after  particle  is 
deposited,  until  it  sometimes  accumulates  in  such  quantities  that 
nearly  all  the  teeth  are  almost  entirely  encrusted  with  it.  It  is 
always,  however,  found  in  greatest  abundance  on  the  outer  sur- 
faces of  the  superior  molars  and  the  inner  surfaces  of  the  infe- 
rior incisors,  and  it  is  opposite  to  these  that  the  mouths  of  the 
salivary  ducts  open. 


EFFECTS  OF  SALIVARY  CALCULUS   UPON   THE   TEETH,  GUMS 
AND  ALVEOLAR  PROCESSES. 

The  effects  of  the  presence  of  this  substance  on  the  teeth  are 
always  pernicious,  though  sometimes  more  so  than  at  others. 
An  altered  condition  of  the  fluids  of  the  mouth,  diseased  gums, 
and  not  unfrequently  the  gradual  destruction  of  the  alveolar 
processes,  and  the  loosening  and  loss  of  the  teeth,  are  among 
the  consequences  that  result  from  it.  But  beside  these,  other 
effects  are  occasionally  produced,  among  which  may  be  enume- 


f 


452  EFFECTS    OF    SALIVARY   CALCULUS. 

rated :  tumors  and  spongy  excrescences  of  the  gums,  of  various 
kinds;  necrosis  anctexfoliation  of  the  alveolar  processes,  and  of 
portions  of  the  maxillary  bones;  hemorrhage  of  the  gums;  ano- 
rexia, derangement  of  the  whole  digestive  apparatus  and  foul 
breath;  catarrh,  cough,  diarrhoea;  diseases  of  various  kinds  in 
the  maxillary  antra  and  nose;  pain  in  the  ear,  head-ache;  mel- 
ancholy, hypochondriasis,  &c.  The  character  of  the  effects, 
however,  both  local  and  constitutional,  depends  upon  the  quan- 
tity and  consistence  of  the  tartar,  and  upon  the  temperament  of 
the  individual  as  well  as  the  state  of  the  general  health ;  the  two 
former  of  these  are  determined  by  the  two  latter,  and  by  the 
attention  paid  to  the  cleanliness  of  the  teeth.  If  this  last  be 
propei'ly  attended  to,  salivary  calculus,  no  matter  how  great  the 
constitutional  tendency  to  its  formation,  will  not  collect  in  large 
quantity  upon  the  teeth.  The  importance,  therefore,  of  its  con- 
stant observance  cannot  be  too  strongly  impressed  upon  the  pa- 
tient, especially  upon  those  in  whom  there  exists  a  great  tendency 
to  its  deposition. 

The  teeth  and  their  contiguous  parts  suffer  more  from  accumu- 
lations of  this  substance,  than  almost  any  other  cause.  Caries 
is  not  much  more  destructive  to  them.  When  permitted  to  ac- 
cumulate for  any  great  length  of  time,  the  gums  become  so  mor- 
bidly sensitive,  that  a  tooth-brush  cannot  be  used  without  caus- 
ing pain  :  consequently,  the  cleanliness  of  the  mouth  is  not  at- 
tempted, and  thus,  no  means  being  taken  to  prevent  its  forma- 
tion, it  accumulates  with  increased  rapidity,  until  the  teeth,  one 
after  another,  fall  in  quick  succession  victims  to  its  desolating 
ravages. 

It  sometimes  not  only  undermines  the  constitution,  by  occa- 
sioning discharges  of  fetid  matter  from  tlie  gums,  and  corrupting 
the  fluids  of  the  mouth ;  but  it  also  renders  the  breath  exceed- 
ingly unpleasant  and  off'ensive.  So  nauseating  and  disagreeable 
is  the  odor  which  some  descriptions  of  tartar  exhale,  that  the 
atmosphere  of  a  whole  room  is  contaminated  by  it  in  a  few 
minutes. 


RExMOVAL    OF    SALIVARY    CALCULUS.  453 


MANNER  OF  REMOVING  SALIVARY  CALCULUS. 

This  is  an  operation  of  great  importance  to  the  health  of  the 
gums,  alveolar  processes  and  teeth.  But  from  a  misconception 
of  its  nature,  rather  than  from  fear  of  pain,  many  are  much  op- 
posed to  it:  and  notwithstanding  the  universal  admiration  in 
which  clean  and  Avhite  teeth  are  held,  they  will  suffer  the  beauty 
of  these  organs  to  be  destroyed,  rather  than  submit  to  its  per- 
formance. There  are  some,  indeed,  who  though  scrupulously 
particular  in  everything  that  regards  dress,  seem,  nevertheless, 
to  consider  cleanliness  of  the  mouth  as  unworthy  of  notice. 

For  the  removal  of  tartar  from  the  teeth,  a  variety  of  instru- 
ments are  necessary,  which  should  be  so  constructed,  that  they 
may  be  easily  applied  to  every  part  of  every  tooth.  Those  in 
common  use  among  dental  practitioners  are  so  very  similar  in 
in  their  shape,  and  so  well  known,  that  we  do  not  deem  it  neces- 
sary to  point  out  the  minute  differences  of  construction,  or  even 
to  give  a  general  description  of  the  instruments  themselves.  The 
instruments  should  be  light,  made  with  ivory,  ebony  or  cocoa 
handles,  and  tapering  from  a  little  above  the  ferule,  both  ways ; 
and  the  points  of  the  instruments  should  be  delicately  shaped  so 
as  readily  to  pass  below  the  free  edge  of  the  gum.  The  success 
of  the  operation  depends  much  upon  the  careful  removal  of  every 
particle  of  deposit ;  for  which  a  heavy,  clumsy  or  large  bladed 
instrument  is  wholly  unsuited.  If  any  particles  of  tartar  be  suf- 
fered to  remain,  they  will  irritate  the  gums,  and  serve  as  nuclei 
for  immediate  re-accumulations. 

The  adhesion  of  tartar  to  the  teeth  is  sometimes  so  great,  that 
considerable  force  is  required  for  its  removal,  even  when  the 
sharpest  and  best  tempered  instruments  are  employed :  but  ordi- 
narily it  may  be  removed  with  ease.  Considerable  tact,  however, 
is  necessary  to  perfoi*m  the  operation  in  a  skillful  manner;  more 
than  most  persons,  from  its  apparent  simplicity,  imagine.  This 
skill  can  only  be  acquired  by  practice.  Tartar  may  be  taken 
from  the  outer  and  inner  surfaces  of  the  teeth  without  much 
difficulty ;  but  the  removal  of  it  from  between  them,  is  more 
troublesome,  and  can  only  be  effected  by  means  of  very  thin, 
sharp  pointed  instruments. 


454  REMOVAL    OF    SALIVARY    CALCULUS. 

Several  sittings  are  sometimes  necessary  for  the  completion  of 
the  operation,  especially  when  the  tartar  has  accumulated  in  very 
large  quantities.  In  all  cases  of  this  sort,  it  should  he  first 
removed  from  between  the  edges  of  the  gums,  and  the  necks  of 
the  teeth.  During  the  intervals  between  the  several  operations, 
the  mouth  should  be  gargled  several  times  a  day,  with  some 
cooling  and  astringent  wash  ;  but  on  this  subject  more  particular 
directions  will  be  given  in  the  next  chapter. 

During  the  removal  of  tartar  from  the  teeth,  the  gums  often 
bleed  very  freely ;  and  when  much  swollen  and  spongy,  it  may 
be  well  to  promote  it  by  holding  tepid  water  in  the  mouth. 
When  the  lower  incisors  are  loose,  as  is  often  the  case,  the  ope- 
ration should  be  proceeded  with  very  cautiously,  especially  when 
the  tartar  is  very  hard  and  adheres  with  great  tenacity. 

Chemical  agents  are  sometimes  employed  for  the  removal  of 
salivary  calculus,  especially  such  of  the  mineral  acids  as  are 
supposed  to  have  less  afiinity  for  the  lime  of  the  teeth  than  the 
phosphoric  with  which  it  is  combined;  but  it  is  scarcely  neces- 
sary to  say,  that  any  acid  capable  of  dissolving  tartar  will  act 
upon  these  organs.  The  use  of  all  such  agents  should  be  most 
scrupulously  avoided.  Nearly  all  acids,  both  mineral  and  vege- 
table, as  has  been  shoAvn  in  a  preceding  part  of  this  work,  are 
prejudicial  to  the  teeth.  Their  careless  administration  by  phy- 
sicians is  a  fruitful  source  of  injury  to  the  teeth.  And  they 
certainly  should  form  no  part  of  any  dentrifice,  or  be  in  any 
way  used  for  the  removal  of  stains  of  any  kind  from  the  teeth. 


CHAPTER   SECOND. 
DISEASES  OF  THE  GUMS. 

The  gums  and  alveolar  processes,  from  apparently  the  same 
cause,  frequently  assume  various  morbid  conditions.  An  unheal- 
thy action  in  one  is  almost  certain  to  be  followed  by  disease  in 
the  other.  The  most  common  form  of  disease  to  which  these 
parts  are  subject  is  usually,  though  very  improperly,  denominated 
scurvy,  from  its  supposed  resemblance  to  scorbutus,  a  disease 
belonging  to  the  Class  CA€HEXiJi;,  and  Order  Impetiginis,  of  Cul- 
len  ;  to  which,  however,  it  bears  no  resemblance.  Instead,  there- 
fore, of  continuing  the  use  of  this  term,  we  propose  to  treat  the 
disease  under  the  name  of  chronic  inflammation  and  tumefaction 
of  the  gums,  attended  by  recession  of  their  margins  from  the 
necks  of  the  teeth,  which  seems  to  express  more  clearly  the  con- 
dition of  the  parts  and  the  nature  of  the  disease.  The  gums 
sometimes,  though  less  frequently,  become  the  seat  of  acute  in- 
flammation. The  other  affections  to  which  they  are  liable  will 
be  noticed  in  their  appropriate  place. 

The  diseases  of  the  gums  and  alveolar  processes  are  divided  by 
Mr.  Bell  into  two  classes :  those  which  are  the  result  of  local 
irritation,  and  those  which  arise  from  constitutional  causes. 

Were  it  not  for  local  irritation  in  these  parts,  the  constitu- 
tional tendencies  to  disease  would  rarely  manifest  themselves; 
and,  on  the  other  hand,  were  it  not  for  constitutional  tendencies, 
the  effects  of  local  irritation  would  seldom  be  of  a  serious  cha- 
racter. "Thus,"  says  Mr.  Bell,  "the  same  cause  of  irritation 
which,  in  a  healthy  person,  would  occasion  a  simple  abscess, 
might,  in  a  different  constitution,  result  in  ulceration  of  a  decidedly 
cancerous  type ;  or  in  the  production  of  fungoas  tumors,  or  the 
formation  of  scrofulous  abscesses." 

Each  constitution  has  its  peculiar  tendency  ;  or  in  other  words, 
is  more  favorable  to  the  development  of  some  forms  of  disease, 
than  others  ;  and  this  tendency  is  always  increased  or  diminished, 


456  DISEASES    OF    THE    GUMS. 

according  to  the  healthy  or  unhealthy  performance  of  the  func- 
tional operations  of  the  body  generally.  Thus,  derangement  of 
the  digestive  organs  increases  the  tendency,  in  an  individual  of 
a  mucous  habit,  to  certain  forms  of  diseased  action  in  particular 
organs,  and  especially  in  the  gums.  A  local  irritant,  which 
would  otherwise  produce  only  a  slight  inflammation  of  the 
margins  of  the  gums,  would  now  give  rise  to  turgidity  and 
sponginess  of  their  whole  structure.  The  same  may  be  said  with 
regard  to  a  person  of  a  scrofulous  or  scorbutic  habit. 

The  susceptibility  of  the  gums  to  the  action  of  morbid  irritants, 
is  always  increased  by  enfeeblement  of  the  vital  powers  of  the 
body.  Hence,  persons  laboring  under  excessive  grief,  melan- 
choly, or  any  other  affection  of  the  mind ;  or  under  constitutional 
disease,  tending  to  enervate  the  vital  energies  of  the  system  ; 
are  exceedingly  subject  to  inflammation,  sponginess  and  ulcera- 
tion of  the  gums.  But,  notwithstanding  the  increase  of  suscepti- 
bility which  the  gums  derive  from  certain  constitutional  causes 
and  states  of  the  general  health  ;  these  influences  may,  in  the 
majority  of  cases,  be  counteracted  by  a  strict  observance  of  the 
rules  of  dental  hygiene ;  or,  in  other  words,  by  constant  and 
regular  attention  to  the  cleanliness  of  the  teeth. 

A  local  disease,  situated  in  a  remote  part,  often  has  the  effect 
of  diminishing  the  tendency  in  the  gums  to  disease ;  but  when, 
from  its  violence  or  long  continuance,  the  general  health  becomes 
implicated,  the  susceptibility  of  these  parts  is  augmented. 

Although  deriving  their  predisposition  to  disease  from  a  spe- 
cific, morbid  constitutional  tendency,  they,  nevertheless,  when 
diseased,  contribute  in  no  small  degree  to  derange  the  whole 
organism.  Their  unhealthy  action  vitiates  the  fluids  of  the 
mouth,  and  renders  them  unfit  for  the  purposes  for  which  they 
are  designed ;  hence,  when  these  parts  are  restored  to  health, 
whether  from  the  loss  of  diseased  teeth,  or  the  treatment  to 
which  they  may  have  been  subjected,  the  condition  of  the  general 
health  is  always  immediately  improved. 

Thus,  while  the  susceptibility  of  the  gums  to  morbid  im- 
pressions is  influenced  by  the  state  of  the  general  health,  the 
latter  is  equally  influenced  by  the  condition  of  the  former.  And, 
not  only  is  a  healtliy  condition  of  the  gums  essential  to  the  gene- 
ral health,  but  it  is  also  essential  to  the  health  of  the  teeth  and 


INFLAMMATION    OF    THE    GUMS.  457 

;\lveolar  processes.  From  the  intimate  relation  that  subsists 
between  the  former  and  latter,  disease  cannot  exist  in  one,  with- 
out in  some  degree  affecting  the  other.  Caries  of  the  teeth,  for 
example,  often  gives  rise  to  inflammation  of  the  gums  and  alveolo- 
deutal  periosteum;  on  the  other  hand,  inflammation  of  these 
parts  vitiates  the  fluids  of  the  mouth,  and  causes  them  to  exert 
a  deleterious  action  upon  the  teeth,  and  also  excites  more  or  less 
constitutional,  derangement. 

ACUTE  INFLAMMATION  OF  THE  GUMS. 

Acute  inflammation  of  the  gums  frequently  occurs  in  connec- 
tion with  stomatitis,  or  general  inflammation  of  the  mucous  mem- 
brane of  the  buccal  cavity,  which  appears  under  a  great  variety 
of  forms.  In  this  case  the  inflammatory  action  does  not  always 
extend  to  the  subjacent  fibro-cartilaginous  structure ;  but  the 
local  disease  is  often  complicated  with  other  disorders,  the  treat- 
ment of  Avhich  comes  more  properly  within  the  province  of  the 
medical  than  that  of  the  dental  practitioner.  Ulitis,  or  acute 
inflammation  of  the  gums,  is  in  most  cases,  a  purely  local  disease, 
arising  usually  from  the  irritation  of  dentition,  or  as  a  conse- 
quence of  periodontitis.  It  often  extends  to  the  submaxillary 
glands  and  muscles  of  the  face,  and  is  attended  by  swelling  and 
other  morbid  phenomena.  But  as  this  form  of  inflammation  of 
the  gums  is  treated  of  in  connection  with  other  subjects,>it  will 
not  be  necessary  to  repeat  what  we  have  said  elsewhere  concern- 
ing it. 

CHRONIC  INFLAMMATION  AND  TUMEFACTION  OF  THE  GUMS 
ATTENDED  BY  RECESSION  OF  THEIR  MARGINS  FROM  THE 
TEETH. 

The  affection  which  we  are  now  about  to  consider  has  been 
variously  designated.  Jourdain  and  other  French  writers  term 
it,  in  its  more  advanced  stages,  conjoined  suppuration  ;  because 
it  is  then  complicated  with  a  discharge  of  purulent  matter  from 
between  the  edges  of  the  gums  and  the  necks  of  the  teeth,  and 
with  a  gradual  destruction  of  the  alveolar  processes.  Dr. 
Koecker  calls  it  the  devastating  process,  because  it  is  attended 
by  wasting  of  the  gums  and  alveoli.  But  it  is  more  frequently 
30 


4o8  INFLAMMATION    OF    THE    GUMS. 

treated  of  under  the  appellation  of  scurvy  than  under  any  other 
name. 

Chronic  inflammation  of  the  gums  may  exist  for  years  without 
being  attended  with  suppuration,  or  recession  of  their  margins 
from  the  necks  of  the  teeth  ;  but  these  phenomena  are  sooner  or 
later  developed  according  to  the  amount  of  local  irritation  and 
the  state  of  the  constitutional  health  and  habit  of  body.  With 
the  occurrence  of  inflammation  the  margins  of  the  gums  gra- 
dually lose  their  festooned  appearance ;  become  thick,  spongy 
and  rounded  ;  and  ultimately,  on  being  pressed,  purulent  matter 
is  discharged  from  between  them  and  the  necks  of  the  teeth. 
Their  sensibility  is  increased,  and  they  bleed  from  the  most  trifl- 
ing injury. 

The  diseased  action  usually  first  develops  itself  in  the  gums 
around  the  lower  front  teeth  and  the  upper  molars,  opposite  the 
mouths  of  the  salivary  ducts ;  also  in  the  immediate  vicinity  of 
aching,  decayed,  dead,  loose,  or  irregularly  arranged  teeth,  or 
in  the  neighborhood  of  roots  of  teeth ;  from  thence  it  extends  to 
the  other  teeth.  The  rapidity  of  its  progress  depends  on  the 
age,  state  of  the  general  health,  temperament  and  habit  of  body 
of  the  individual,  and  the  character  of  the  local  irritants  which 
have  given  rise  to  it.  It  is  always  more  rapid  in  persons  ad- 
dicted to  the  free  use  of  spirituous  liquors,  and  in  individuals  in 
whom  there  exists  a  scorbutic  tendency ;  or  who  have  sufiered 
from  venereal  disease,  or  from  the  constitutional  effects  of  a 
mercurial  treatment  used  to  cure  this  or  other  diseases. 

The  inflammation  may  be  confined  to  the  gums  of  two  or  three 
teeth,  or  it  may  extend  to  the  gums  of  all  the  teeth,  in  one  or 
both  jaws. 

As  the  disease  advances,  the  gums  begin  to  recede  from  the 

necks  of  the  teeth,  and  the  al- 
FiG.  IGO.  ' 

veoli  to  waste,  and  the  teeth,  as 

they  lose  their  support,  loosen 
and  ultimately  drop  out.  In 
Fig.  160  is  represented  a  case 
in  which  nearly  one-half  of  the 
roots  of  the  lower  incisors  have 
become  exposed  by  this  devas- 
tating process. 


INFLAMMATION    OF   THE    GUMS.  459 

But  the  loss  of  the  teeth,  though  it  puts  a  stop  to  the  local 
disease,  is  not  the  only  bad  effect  that  results  from  it.  Consti- 
tutional symptoms  often  supervene,  more  vital  organs  become 
implicated,  and  the  health  of  the  general  system  is  sometimes 
very  seriously  impaired.  Hence,  the  improvement  often  ob- 
served after  the  loss  of  the  teeth,  in  the  general  health  of  per- 
sons whose  mouths  have  for  a  long  time  been  affected  with  this 
disease.  No  condition  of  the  mouth  has  a  greater  tendency  to 
deteriorate  its  secretions,  and  impair  the  functions  of  mastica- 
tion and  digestion  than  the  one  now  under  consideration. 

In  forming  an  opinion  of  the  injury  likely  to  result  from  the 
disease,  the  dentist  should  be  governed  not  only  by  the  health 
and  age  of  the  patient,  and  the  local  causes  concerned  in  its  pro- 
duction ;  but  he  should  also  endeavor  to  ascertain  whether  it  is 
connected  with  a  constitutional  tendency,  or  is  purely  a  local 
affection.  Some  have  been  led  to  believe,  that  the  wasting  of 
the  gums  and  alveolar  processes  may  sometimes  take  place  with- 
out being  connected  with  any  special  local,  or  constitutional 
cause ;  that  it  is  identical  with  that  process  by  which  the  teeth 
of  aged  persons  are  removed,  and  that  when  it  occurs  in  persons 
not  past  the  meridian  of  life,  it  is  symptomatic  of  a  kind  of  pre- 
mature old  age. 

Mr.  Bell,  on  this  subject,  remarks:  "In  forming  a  judgment 
upon  cases  of  this  description,  however,  and  even  upon  those  in 
which  the  loss  of  substance  is  associated  with  more  or  less  of 
diseased  action,  it  is  necessary  to  recollect  that  the  teeth  are 
L'enerally  removed  in  old  age  by  this  identical  mode ;  namely, 
the  destruction  of  their  support,  by  the  absorption  of  the  gums 
and  alveolar  processes ;  and  as  this  step  toward  general  decay 
commences  at  very  different  periods  in  different  constitutions,  it 
may,  doubtless,  in  many  cases,  even  in  persons  not  past  the  mid- 
dle period  of  life,  be  considered  as  an  indication  of  a  sort  of  pre- 
mature old  age,  or  an  anticipation,  at  least,  of  senile  decay,  as 
far  as  regards  these  parts  of  the  body." 

The  loss  of  the  teeth,  from  the  wasting  of  the  gums  and  alve- 
olar processes,  although  occurring  frequently  in  advanced  life, 
is  not  a  necessary  consequence  of  senility,  for  we  occasionally 
see  persons  of  seventy,  and  even  eighty  years  of  age,  whose 
teeth  are  as  firmly  fixed  in  their  sockets  and  their  gums  as  little 


460  CAUSES    OF    INFLAMMATION    OF    THE    GUMS. 

impaired,  as  in  individuals  at  twenty.  We  do  not  recollect  ever 
to  have  seen  a  case  of  this  kind  in  which  there  Avas  not  evidently 
some  diseased  action  in  the  gums.  But  it  is  of  little  importance 
whether  it  be  the  result  of  old  age,  a  constitutional  tendency, 
functional  derangement  of  some  other  part,  or  local  irritation, 
since  the  consequences  resulting  from  such  loss  are  always  the 
same. 

The  gums  after  having  been  once  the  seat  of  chronic  in- 
flammation, are  ever  after  more  susceptible  to  the  action  of 
morbid  irritants. 

CAUSES. 

The  immediate  or  exciting  cause  of  inflammation  of  the  gums, 
is  local  irritation,  produced — by  salivary  calculus ;  by  carious, 
dead,  loose  or  aching  teeth,  or  roots  of  teeth ;  or  by  teeth  which 
occupy  a  wrong  position,  or  that  are  crowded  in  their  arrange- 
ment. It  may  also  be  produced  by  very  hard  teeth,  Avhich,  in 
consequence  of  their  density,  possess  only  a  very  low  degree  of 
vitality ;  for  cases  of  recession  of  the  gums,  in  which  a  very 
slight  inflammatory  action  exists,  are  frequently  met  with  in  in- 
dividuals having  teeth  of  this  description.  This  can  only  be  ex- 
plained, by  supposing  a  want  of  congeniality  between  these 
organs  and  the  more  sensitive  and  highly  vitalized  parts  with 
which  they  are  in  immediate  contact.  The  same  thing  is  ob- 
served when  the  vitality  of  the  teeth  is  weakened  by  age,  which 
Mr.  Bell  regards  as  an  indication  of  senile  decay. 

The  secretions  of  the  mouth,  especially  the  mucus,  are  often 
rendered,  by  certain  conditions  of  the  general  system,  so  acrid 
as  to  become  a  source  of  irritation  to  the  gums. 

Dr.  Koecker,  who  has  had  the  most  ample  opportunities  of 
observing  this  affection  in  all  its  various  forms,  says  that  he  has 
never  seen  a  case  in  which  tartar  was  not  present.  That  this 
is  so  in  a  large  majority  of  the  cases,  there  is  no  question ;  but 
that  it  is  in  all,  is  certainly  a  mistake.  The  author  has  met 
with  many  in  which  not  the  smallest  deposit  could  be  detected. 

The  disease  attacks  persons  of  every  age,  rank,  and  condi- 
tion ;  and  in  every  country,  climate,  and  nation.  "  I  have  ob- 
served," says  Dr.  Koecker,  "the  inhabitants  of  the  most  widely 
separated    countries,     Russians,    French,    Italians,    Spaniards, 


CAUSES    OF   INFLAMMATION    OF   THE    GUMS.  461 

Portuguese,  English,  Africans,  East  and  West  Indians,  and 
those  of  the  United  States,  to  be  all  more  or  less  liable  to  it." 

It  is,  however,  more  frequently  met  with  in  the  lower  than  in 
the  higher  classes  of  society.  Persons  who  pay  no  attention  to 
the  cleanliness  and  health  of  their  teeth  are  particularly  subject 
to  it.  With  sailors,  and  those  who  live  principally  on  salt  pro- 
visions, it  is  very  common.  "Persons  of  robust  constitution," 
says  Dr.  Koecker,  "  are  much  more  liable  to  this  affection  of  the 
gums  than  those  of  delicate  habit ;  and  it  shows  itself  in  its 
worst  form  after  the  age  of  thirty,  oftener  than  at  any  earlier 
period." 

To  the  causes  of  irritation,  which  have  already  been  enume- 
rated, may  be  added — accumulation  of  extraneous  matter  on  the 
teeth  and  along  the  edges  of  the  gums ;  exodontosis  ;  artificial 
teeth  badly  inserted,  or  made  of  improper  material ;  and  dental 
operations  badly  performed.  The  use  of  improper  tooth-brushes 
and  powders,  especially  charcoal,  may  be  reckoned  among  its 
exciting  causes.  The  irritability  of  the  gums  is  sometimes  in- 
creased by  the  use  of  acids ;  at  other  times  it  is  diminished. 

Every  condition  of  the  general  system,  tending  to  increase  the 
susceptibility  of  the  gums  to  the  action  of  local  irritants,  favors 
the  production  of  the  disease.  Every  thing  that  tends  to  induce 
such  conditions  may  be  regarded  as  a  predisposing  cause ;  such 
as,  bilious  and  inflammatory  fevers,  the  excessive  use  of  mercurial 
medicines,  the  venereal  virus,  intemperance  and  debauchery. 
Any  deterioration  of  the  fluids  of  the  body  is  peculiarly  conducive 
to  it.  Persons  of  cachectic  habit  are  far  more  subject  to  it,  and 
generally  in  its  worst  forms,  than  those  individuals  in  the  enjoy- 
ment of  good  health. 

Strumous  individuals  sometimes  have  an  affection  of  the  gums, 
which  differs  in  many  respects  from  the  one  just  described.  The 
gums,  instead  of  being  purple  and  swollen,  are  pale  and  harder 
than  ordinary  ;  and,  on  being  pressed,  discharge  muco-purulent 
matter,  of  a  dingy  white  color.  They  often  remain  in  this  con- 
dition for  years,  without  appearing  to  undergo  any  structural 
alteration,  or  to  affect  the  alveolar  processes.  This  form  of  the 
disease  is  principally  confined  to  persons  who  have  very  white 
teeth ;  it  is  much  less  likely  to  attack  males  than  females ;  and 
has  never,  so  far  as  we  have  been  able  to  ascertain,  been  men- 


462  TREATMENT   OF   INFLAMMATION    OF   THE    GUMS. 

tioned  by  any  dental  writer.  Mr.  Fox  speaks  of  ulceration  of 
the  gums  in  scrofulous  children  ;  but  that  is  of  frequent  occur- 
rence, and  is  characterized  by  the  usual  phenomena  of  inflamma- 
tion. This  disease  now  spoken  of  rarely  occurs  before  the  age 
of  eighteen  or  twenty ;  and  it  seems  to  be  the  result  of  impaired 
nutrition.  The  gums  exhibit  no  sign  of  inflammatory  action;  on 
the  contrary,  they  are  paler,  less  sensitive,  and  possess  less 
warmth  than  usual.  It  is  never  attended  with  tumefaction  or 
absorption,  except  in  its  advanced  stages  ;  whereas,  the  affection 
of  which  Mr.  Fox  speaks  is  always  accompanied  by  both. 

TREATMENT. 

In  the  treatment  of  inflamed,  spongy  and  ulcerated  gums,  the 
first  thing  claiming  attention,  is  the  removal  of  the  exciting 
causes.  If  there  are  dead  or  loose  teeth  in  the  mouth,  or  teeth 
which,  from  their  position,  act  as  mechanical  irritants,  they  should 
be  at  once  extracted.  The  remaining  teeth  should,  at  the  same 
time,  be  freed  from  tartar  and  all  other  irritating  depositions. 

Dr.  Koecker  goes  so  far  as  to  recommend  the  extraction  of  any 
molar  tooth,  particularly  in  the  upper  jaw,  which  has  lost  its  an- 
tagonist ;  believing  that  a  tooth  under  such  circumstances  is  a 
source  of  irritation  to  the  alveolo-dental  periosteum  and  gums. 
He  says,  "  In  this  manner  the  loss  of  one  molar  tooth  produces 
the  destruction  of  its  remaining  antagonist.  This  is  efi"ected, 
however,  after  a  struggle  of  nature,  of  very  long  duration,  which 
always  involves,  in  some  degree,  all  the  other  teeth  in  a  like  dis- 
eased condition  ;  it  is  necessary,  therefore,  to  prevent  this  morbid 
condition,  particularly  pernicious  in  this  disease,  by  the  extrac- 
tion of  the  tooth,  or  any  molar  so  situated." 

Although  a  molar  tooth,  after  having  lost  its  antagonist,  is 
sometimes  a  source  of  irritation,  it  may  often  remain  with  im- 
punity. Its  removal  is  necessary  only  when  it  acts  as  an  irritant 
to  the  gums;  and  it  may,  in  a  majority  of  cases,  be  prevented 
from  doing  this  by  keeping  it  constantly  clean. 

It  is  essential,  in  the  treatment  of  the  disease  under  considera- 
tion, that  a  decided  impression  be  made  upon  it  at  once ;  conse- 
quently, no  time  should  be  lost  in  the  removal  of  local  exciting 
causes.     "The  advantage  derived  from  this  operation,"  (extrac- 


TREATMENT    OF    INFLAMMATION    OF   THE    GUMS.  463 

tion  of  dead,  loose,  or  irritating  teeth,)  says  Dr.  Koecker,  "would 
be  either  partly  or  wholly  lost,  were  it  performed  at  different 
periods."  This  observation  has  been  verified  by  the  author 
more  than  once.  When  he  has  been  prevented  by  the  timidity 
of  his  patient  from  extracting  all  the  offending  teeth,  at  the  first 
sitting,  he  has  always  found  the  cure  much  retarded,  and,  in 
some  instances,  almost  entirely  defeated. 

Having  extracted  such  teeth  as  it  may  be  necessary  to 
remove.  Dr.  Koecker  thinks  it  better  to  wait  ten  or  fifteen  days 
before  the  tartar  is  removed.  The  author  has  never  been  able 
to  discover  any  advantage  in  such  delay  ;  on  the  contrary,  he 
regards  it  as  important  that  as  much  as  possible  should  be  taken 
from  the  teeth  at  the  time  of  the  extraction.  Several  sittings, 
however,  are  often  required  for  its  complete  removal. 

The  bleeding  from  the  gums  and  sockets,  occasioned  by  these 
several  operations,  should  be  promoted  by  frequently  washing 
the  mouth  with  warm  water;  and  when  the  gums  are  much 
swollen,  advantage  will  be  derived  from  scarifying  them  freely 
every  three  or  four  days  with  a  sharp  lancet.  This  last  opera- 
tion is  highly  recommended  by  Hunter,  Fox  and  Bell,  and 
indeed  its  good  effects  are  so  apparent  that  it  should  never  be 
neglected. 

The  cure  may  be  hastened  by  washing  the  mouth  several  times 
a  day  with  some  tonic  and  astringent  lotion.  The  author  has 
found  the  following  to  be  very  serviceable : 

^•.     Powdered  nut  galls, 

"         Peruvian  bark,      each,  2  drachms. 

"         orris  root,  1  drachm. 

Infusion  of  roses,  4  fluid  ounces. 

The  infusion  to  stand  for  a  day  or  so  upon  the  powders,  with  frequent  stirring  ; 

then  decant  and  filter. 

Mr.  Fox  says  great  benefit  is  derived  from  the  use  of  sea 
water,  and  he  recommends  it  whenever  it  can  be  procured ;  add- 
ing, that  if  the  gums  be  tender,  it  should  be  used  warm.  We 
are  unable  to  speak  of  the  merits  of  this  remedy  from  experi- 
ence, never  having  tried  it.  We  have,  in  cases  where  there  was 
much  soreness  and  ulceration  of  the  gums,  prescribed  the  fol- 
lowing : 


464  TREATMENT    OF   INFLAMMATION    OF    THE    GUMS. 

I^:     Borax,  2  scruples. 

Honey,  1  fluid  ounce. 

Sage  tea,  4     "      ounces. 

This  is  a  favorite  and  very  general  domestic  remedy,  aud  will  be  found  very 
soothing  and  healing. 

As  a  wash  for  the  mouth,  Dr.  Fitch  recommends  a  decoction 
of  the  green  inner  bark  of  white  oak,  which  we  have  found 
beneficial.  The  following  are  recommended  by  Dr.  Koecker,  as 
being  very  serviceable: 

"  Take  of  clarified  honey,  three  ounces,  and  of  vinegar,  one 
ounce.  This,  diluted  in  the  proportion  of  three  tablespoonfuls 
to  a  pint  of  warm  sage  tea,  or  water,  may  be  used  frequently 
during  the  day, 

"  Take  of  clarified  honey,  and  of  the  tincture  of  bark,  two 
ounces  each.     Mix  and  dilute  as  above. 

"  Take  of  honey,  and  of  the  tincture  of  myrrh,  two  ounces 
each.     Mi.x  and  use  as  above." 

Mr.  Bell  recommends  the  following; 

I^;     Alum,  2  drachms. 

Decoction  of  Peruvian  barli,  2  fluid  ounces. 

Infusion  of  roses,  2      •'         " 

But  when  the  last  prescription  is  used,  the  mouth,  immediately 
after,  should  be  thoroughly  washed  with  water  and  a  soft  brush, 
to  prevent  the  sulphuric  acid  of  the  alum  from  exercising  a 
hurtful  effect  upon  the  teeth. 

The  pleasantcst,  and  at  the  same  time  the  most  efficacious, 
mouth-wash  which  the  author  has  ever  employed  is  the  following : 

I^ :    South  American  soap  bark,  8  ounces. 

Pyrethrum,      ■\ 

Orris  root,        (  ,  , 

'        y    each,        1  ounce. 
Benzoic  acid,    | 

Cinnamon,       ) 

Tannic  acid,  4  drachms. 

Borax,  4  scruples. 

Oil  of  wintergreen,  2  fluid  drachms. 

Oil  of  peppermint,  4  fluid  drachms. 

Cochineal,  3  drachms. 

White  sugar,  1  pound. 

Alcohol,  3  pints. 

Pure  water,  5  pints. 

Mix  the  ingredients  thoroughly,  digest  for  six  days  and  filter. 


i 


TKEATMENT  OF  INFLAMMATION  OF  THE  GUMS.     465 

If,  notwithstanding  the  use  of  the  means  here  recommended, 
matter  still  be  discharged  from  around  the  necks  of  the  teeth, 
and  should  the  gums  continue  spongy,  and  manifest  no  disposi- 
tion to  heal,  their  edges  may  be  touched  with  a  strong  solution 
of  the  nitrate  of  silver.  This  will  seldom  fail  to  impart  to  them 
a  healthy  action.  It  may  be  used  in  the  proportion  of  from  three  to 
twelve  grains  to  one  ounce  of  water.  The  most  convenient 
mode  of  applying  it  is  with  a  camel's-hair  pencil.  Its  use  is 
recommended  by  Mr.  Fox,  and  will  often  succeed  when  other 
remedies  fail.  In  those  cases  where  the  matter  discharged  from 
the  edge  of  the  gum  has  a  nauseating  and  disagreeable  odor,  "a 
weak  solution,"  says  he,  "is  an  excellent  remedy  for  rendering 
the  mouth  sweet  and  comfortable;"  but  in  using  it  in  this  way, 
precaution  is  necessary  to  prevent  it  from  getting  into  the  fauces, 
as,  in  this  case,  it  will  cause  disagreeable  nausea.  An  excellent 
disinfectant,  in  such  cases,  is  a  gargle  made  by  diluting  a  tea- 
spoonful  of  chlorinated  soda  (Labarraque's  solution)  in  four  or 
eight  ounces  of  water.  Or  it  may  be  used  much  stronger  and 
applied  with  a  small  mop  to  the  diseased  parts ;  the  silver  ni- 
trate may  be  applied  in  the  same  way. 

While  the  means  here  directed  for  the  cure  of  the  disease  are 
being  employed,  a  recurrence  of  its  exciting  causes  must  be  stu- 
diously guarded  against.  Tartar  and  foreign  matter  of  every 
kind  should  be  prevented  from  accumulating  on  the  teeth,  by  a 
free  and  frequent  use  of  a  suitable  brush  and  waxed  floss-silk ; 
until  a  healthy  action  be  imparted  to  the  gums,  these  should  be 
used  at  least  five  times  a  day:  immediately  after  rising  in  the 
morning,  after  each  meal,  and  before  retiring  at  night.  The 
application  of  the  brush  may  at  first  occasion  some  pain ;  but  its 
use  should,  nevertheless,  be  persisted  in,  for,  without  it,  all  the 
other  remedies  will  be  of  little  avail.  The  friction  produced  by 
it,  besides  keeping  the  teeth  clean,  is  of  great  service  to  the 
gums,  in  imparting  to  them  a  healthy  action. 

Treatment,  difi"erent  from  that  here  described,  is  necessary  in 
that  form  of  disease  which  we  noticed  as  being  characterized  by 
preternatural  paleness  and  discharge  of  muco-purulent  matter 
from  between  the  edge  of  the  gum  and  the  neck  of  the  tooth. 
In  the  first  case  of  this  disease  treated  by  the  author,  he  directed 
astringent  and  detergent  lotions  to  be  used;  but  these  did  not 


466  MORBID  GROWTH  OF  THE  GUMS. 

produce  the  desired  effect.  Having  been  led  from  his  observa- 
tion in  this  case  to  suspect  that  the  disease  was  connected  with 
some  constitutional  derangement,  and  was  probably  the  result 
of  a  debilitated  condition  of  the  general  system,  he  recom- 
mended, in  the  next  case,  the  use  of  tonics  and  free  exercise  in 
the  open  air.  This  course,  though  attended  with  evident  im- 
provement of  the  general  health,  seemed  to  be  productive  of  no 
benefit  to  the  gums.  They  still  appeared  debilitated,  and  on 
being  pressed,  discharged  matter  from  beneath  their  edges.  He 
advised  a  continuance  of  the  tonics  and  exercise,  and  with  a 
view  of  exciting  inflammation,  touched  the  edges  of  the  gums 
with  nitrate  of  silver.  This  had  the  desired  effect,  and,  as  he 
had  anticipated,  a  ncAV  disease  was  substituted  for  the  old  one; 
for  the  cure  of  which,  he  directed  the  mouth  to  be  washed,  five 
or  six  times  a  day,  with  the  mixture  of  sage  tea,  alum  and  honey, 
and  at  night  and  morning  with  salt  water. 

This  treatment  was  perfectly  successful.  In  about  three  weeks 
the  gums  assumed  a  healthy  appearance,  acquired  their  natural 
color,  and  the  discharge  of  muco-purulent  matter  entirely  ceased. 
He  has  since  had  occasion  to  treat  several  other  cases,  in  all  of 
which  he  adopted  the  same  treatment,  and  with  like  success. 

MORBID  GROWTH  OF  THE  GUMS. 

The  structural  changes  which  take  place  in  the  gums,  as  a 
consequence  of  increased  vascular  action,  are  almost  as  various 
as  are  the  constitutional  tendencies  of  different  individuals. 
Those  characterizing  the  affection  last  noticed,  -consist,  for  the 
most  part,  in  increased  thickness  and  recession  of  their  edges 
from  the  necks  of  the  teeth ;  but  in  the  one  of  which  we  are  now 
about  to  treat,  there  is  morbid  growth  which  is  sometimes  so 
considerable,  that  it  almost  covers  the  crowns  of  the  teeth,  thus 
interfering  very  seriously  with  the  function  of  mastication. 
When  thus  affected,  the  gums  have  a  dark  purple  color,  with 
thick,  smooth  and  rounded  margins ;  and  discharge  almost  con- 
stantly from  their  inner  surface,  a  thin,  purulent  matter,  which 
exhales  an  exceedingly  offensive  odor.  They  bleed  profusely 
from  the  slightest  injury,  and  are  so  sensitive  that  the  pressure 
even  of  the  lips  is  sometimes  attended  with  pain.     They  are  also 


CAUSES    OF    MORBID    GROWTH    OF    THE    GUMS. 


467 


affected  with  a  peculiar  itching  sensation,  which,  at  times,  is  a 
source  of  great  annoyance. 

The  accompanying  engraving  (Fig.  161)  will  convey  to  the 
reader  a  more  correct  idea 
of  the  appearance  of  the 
gums,  when  thus  affected, 
than  any  description  which 
can  be  given.  It  will  be 
perceived  from  this,  that 
the  morbid  growth  extends 
to  the  gums  of  all  the  teeth, 
as  it  usually  does  in  this 
variety  of  diseased  action. 

Among  the  local  and  con- 
stitutional    effects     arising 

from  the  disease  are — offensive  breath  ;  vitiated  saliva;  destruc- 
tion of  the  alveoli,  with  loosening  and  ultimate  loss  of  the  teeth  ; 
impaired  digestion,  with  all  its  disagreeable  concomitants ;  en- 
largement of  the  tonsils  and  bronchitis,  together  with  a  long 
train  of  other  morbid  phenomena. 


CAUSES. 

The  exciting  cause  of  this  peculiar  affection  is  local  irritation, 
produced  by  salivary  calculus,  dead,  diseased  or  irregularly 
arranged  teeth ;  but  the  character  of  the  structural  alteration  is 
evidently  determined  by  some  cachectic  habit  of  body  or  consti- 
tutional tendency.  It  often  attacks  the  gums  of  individuals 
whose  teeth  are  sound  and  well  arranged,  but  the  author  has 
never  met  with  a  case  in  which  tartar  was  not  present ;  though, 
in  some  instances,  the  quantity  was  so  small  as  almost  to  lead 
one  to  doubt  whether  it  could  have  had  much  agency  in  the  pro- 
duction of  the  disease.  But  the  susceptibility  of  the  gums  to 
morbid  impressions,  in  individuals  liable  to  this  affection,  is  usu- 
ally so  great,  that  an  irritant,  which  under  other  circumstances 
would  scarcely  excite  an  increase  of  vascular  action,  gives  rise, 
in  cases  of  this  sort,  to  the  rapid  development  of  an  aggravated 
form  of  disease. 


468  TREATMENT    OF    MORBID    GROWTH    OF    THE    GUMS. 


TREATMENT. 

The  first  thing  to  be  attended  to  in  the  treatment  of  the 
disease,  is  the  removal  of  all  dead  teeth  and  such  others  as  may 
in  any  way  irritate  the  gums.  The  morbid  growth  should  be 
next  removed,  by  making  a  horizontal  incision  entirely  through 
the  diseased  gums  to  the  crowns  of  the  teeth.  This  should  be 
carried  as  far  back  as  the  morbid  growth  extends.  After  this, 
the  gums  should  be  freely  scarified  by  passing  a  lancet  between 
the  teeth  down  to  the  alveoli,  in  order  that  the  vessels  may  be 
completely  divided,  and  discharge  their  accumulated  blood.  This 
should  be  repeated  several  times,  at  intervals  of  four  or  five  days. 
Meanwhile  the  mouth  may  be  washed  three  or  four  times  a  day 
with  some  astringent  and  detergent  lotion,  and  occasionally 
mopped  with  a  weak  solution  of  nitrate  of  silver.  The  tartar 
should  be  removed  as  soon  as  the  gums  have  sufficiently  collapsed 
to  admit  of  the  operation. 

The  progress  of  the  disease  may  be  arrested,  but  a  cure  can- 
not be  affected  by  local  treatment  alone.  Particular  attention 
should  be  paid  to  the  regimen  of  the  patient,  and  such  general 
remedies  prescribed  as  the  peculiar  nature  of  the  case  may  indi- 
cate. Excess  and  intemperance  of  every  kind  must  be  avoided. 
In  cases  of  an  inflammatory  type,  the  diet  should  be  chiefly 
vegetable  :  but  where  there  is  debility,  or  other  cachexia,  animal 
food  should  be  used,  taking  care  to  avoid  all  young  meats,  as 
veal  or  lamb,  all  gross  meats  such  as  pork,  and  all  salt  meats  or 
shell  fish.  Fruits  and  acid  beverages,  such  as  infusions  of  malt 
and  vinegar,  lemon  juice,  spruce  beer,  &c.,  may  be  used  with 
advantage. 

The  teeth  should  be  kept  perfectly  and  constantly  clean.  Not 
a  particle  of  foreign  matter  should  be  permitted  to  remain  be- 
tween them  or  along  the  edges  of  the  gums.  A  scrupulous 
attention  to  this  precaution  is  indispensably  necessary ;  as  it 
constitutes  one  of  the  most  important  remedial  indications. 


I 


MERCURIAL    INFLAMMATION    OF   THE    GUMS.  469 


MERCURIAL   INFLAMMATION  OF   THE  GUMS. 

Small  and  repeated  doses  of  mercurj',  when  carried  to  the 
point  of  salivation,  frequently  give  rise  to  the  development  of 
peculiar  morbid  phenomena  in  the  gums  and  other  parts  of  the 
mouth.  The  first  indication  of  the  specific  action  of  this  power- 
ful medicinal  agent  upon  the  animal  economy,  consists  in  a 
slightly  increased  redness  and  tumefaction  of  the  free  edge  of 
the  gums  around  the  necks  of  the  inferior  incisors.  There  is  a 
characteristic  bluish  color  along  the  edge  of  the  gums,  while  the 
investing  mucous  membrane  of  the  adherent  portion,  a  little 
lower  down,  often  assumes  a  white  color,  owing  to  the  opacity 
of  the  epithelium.  These  appearances  are  followed  by — increased 
secretion  of  saliva  ;  a  strong  metallic  taste  ;  soreness  of  the  teeth 
and  gums ;  inflammation  and  swelling  of  the  mucous  membrane  of 
the  roof  of  the  mouth,  fauces  and  cheeks,  and  the  salivary  glands ; 
swelling  of  the  tongue,  with  increased  redness  of  its  edges,  and 
a  peculiarly  offensive  odor  of  breath.  In  the  meantime,  the 
edges  of  the  gums  about  the  necks  of  the  teeth  swell  and  assume 
an  increase  of  redness  ;  the  saliva  becomes  viscid  and  is  secreted 
in  such  abundance  as  to  flow  from  the  mouth,  and  the  move- 
ments of  the  jaws  are  attended  with  pain.  The  alvcolo-dental 
periosteum  is  thickened,  and  the  teeth  raised  from  their  sockets 
and  loosened.  A  vesicular  eruption  sometimes  appears,  followed 
by  ulceration  and  sloughing  of  the  gums,  and  very  frequently  by 
necrosis  of  large  portions  of  the  alveolar  process  and  maxilla. 
We  were  shown,  a  few  years  since,  the  entire  alveolar  border  of 
both  jaws,  the  necrosis  and  exfoliation  of  which  had  been  occa- 
sioned by  severe  mercurial  salivation,  and  we  have  frequently  had 
occasion  to  remove  portions  both  of  the  superior  and  inferior 
maxillary  bones — the  necrosis  having  been  occasioned  by  the 
use  of  this  medicine. 

By  the  prudent  administration  of  mercury,  salivation  may  be 
induced,  without  causing  the  deplorable  effects  just  described. 
But  the  specific  action  of  this  agent  upon  the  constitution  is 
always  attended  by  more  or  less  tumefaction  and  sponginess  of 
the  gums,  and  when  once  brought  under  its  influence,  however 
perfectly  its  effects  may  have  subsided,  they  are  ever  after  more 


470  TREATMENT    OF    MERCURIAL   INFLAMMATION. 

susceptible  to  morbid  impressions.  Again  it  should  be  remem- 
bered that  very  many  of  these  deplorable  symptoms  follow  the 
use  of  mercurials,  even  where  there  is  no  intention  to  salivate. 
It  is  a  powerful  agent,  capable  of  much  good ;  but  one  which  has 
been  productive  of  untold  mischief,  especially  upon  the  mouth 
and  teeth.  Doubtless  life  must  be  saved  at  the  expense,  if 
necessary,  of  the  teeth.  But  the  peculiar  specific  action  of  this 
medicine  should  forbid  its  constant  and  indiscriminate  employ- 
ment. 

TREATMENT. 

It  is  scarcely  necessary  to  say,  that  until  the  use  of  the  mercury 
is  discontinued,  it  will  be  impossible  to  control  or  even  counter- 
act its  effects  upon  the  gums ;  but  in  mild  cases  these  usually 
soon  disappear  after  the  action  which  it  has  produced  on  the 
general  system  has  completely  subsided.  When  the  gums  con- 
tinue spongy,  the  bowels  should  be  kept  open  with  saline  aperi- 
ents, the  patient  restricted  to  a  fluid  farinaceous  diet,  and  the 
mouth  gargled  several  times  a  day  with  demulcent  decoctions 
and  mild  astringent  lotions,  to  which  it  may  sometimes  be  advi- 
sable to  add  a  little  laudanum.  Washes  made  from  chlorinated 
soda  or  lime  may  be  used  to  correct  the  excessive  fetor  of  the 
breath. 

After  the  action  of  the  medicine  upon  the  system  has  subsided, 
and  the  disease  assumes  a  chronic  form,  the  gums,  as  directed 
by  Mr.  Thomas  Bell,  should  be  freely  scarified  by  passing  a 
lancet  entirely  through  their  substance  between  the  teeth ;  and 
this  operation  should  be  repeated  as  often  as  every  few  days, 
until  they  are  completely  restored.  The  use  of  astringent 
washes  should  at  the  same  time  be  continued,  and  if  there  are 
any  teeth  which,  from  the  loss  of  their  vitality,  or  from  having 
become  very  much  loosened  by  the  partial  destruction  of  their 
sockets,  act  as  irritants,  they  should  be  removed. 

When  the  gums  have  ulcerated,  the  application  of  a  strong 
solution  of  sulphate  of  zinc  or  nitrate  of  silver  with  a  camel's- 
hair  pencil  is  recommended.  Chomel,  an  eminent  French  phy- 
sician, has  employed  vapor  baths  with  advantage,  in  cases  of 
mercurial  stomatitis. 


ULCERATION    OF   THE   GUMS    OF    CHILDREN.  471 


ULCERATION  OF  THE  GUMS  OF  CHILDREN,  ATTENDED  WITH 
EXFOLIATION  OF  THE  ALVEOLAR  PROCESSES. 

The  gums  and  alveolar  processes  of  children  are  occasionally 
attacked  by  a  very  peculiar  form  of  disease,  which  occurs  more 
frequently  during  the  shedding  of  the  temporary  and  the  eruption 
of  the  permanent  teeth,  than  at  any  other  period  of  childhood. 
We  have  never  known  adults  to  be  affected  with  it,  and  to  the 
ordinary  spongy,  inflamed  and  ulcerated  gums,  it  does  not  appear 
to  be  at  all  analogous.  It  bears  a  much  closer  resemblance  to 
cancrum  oris,  yet  differs  in  many  particulars  from  this  disease. 

Among  the  symptoms  which  characterize  the  affection,  are 
itching  and  ulceration  of  the  gums  and  their  separation  from 
tlie  necks  of  the  teeth  and  alveolar  processes ;  there  is,  at  first, 
a  discharge  of  muco-purulent  matter  from  between  the  gums  and 
necks  of  the  teeth,  which  ultimately  becomes  ichorous  and  fetid. 
The  teeth  loosen,  and  the  alveoli  lose  their  vitality  and  exfoliate. 
Ulcers  are  formed  in  various  parts  of  the  mouth,  the  gums  and 
lips  assume  a  deep  red  or  purple  color.  In  the  exfoliation  of 
the  alveolar  processes,  the  temporary,  and  sometimes  the  crowns 
of  the  permanent  teeth  are  carried  away.  The  constitutional 
symptoms  are  :  skin,  for  the  most  part,  dry ;  pulse  small  and 
(juick ;  the  bowels  generally  constipated,  though  sometimes  there 
is  diarrhoea ;  and  to  these  symptoms  may  be  added  lassitude 
and  a  disposition  to  sleep. 

These  may  be  regarded  as  the  prominent  phenomena  of  the 
disease  in  its  most  aggravated  form.  When  exfoliation  of  the 
alveolar  processes  takes  place,  the  symptoms  usually  abate,  and 
sometimes  wholly  disappear.  Delabarre  says,  "  among  the  great 
number  of  children  that  are  brought  to  the  orphan  asylum,  he 
has  had  frequent  occasion  to  notice  singular  complications  of  the 
affection,  as  modified  by  the  strength,  sex,  and  idiosyncrasies  of 
the  different  subjects."  The  gums  and  lips,  in  some,  he  describes 
as  being  of  a  beautiful  red  color ;  in  others,  the  lips  are  rosy 
and  the  gums  pale,  and  sometimes  very  much  swollen.  He  also 
enumerates  among  the  symptoms,  burning  pain  in  the  mucous 
membrane  of  the  cheeks,  and  ulceration,  pain  and  swelling  in 
the  submaxillary  glands. 


472        CAUSES  OF  ULCERATION  OF  THE  GUMS. 

In  the  majority  of  cases,  the  disease  is  confined  to  one  jaw 
and  to  one  side,  though  sometimes  both  are  affected  by  it.  The 
effect  on  the  permanent  teeth,  in  all  the  cases  which  have  fallen 
under  the  notice  of  the  author,  was  injurious,  though  Delabarre 
says,  that  in  children  who  have  reached  their  seventh  or  eighth 
year,  the  teeth  are  not  injured,  except  that  they  may  be  badly 
arranged,  in  consequence  of  the  want  of  a  proper  development 
of  the  jaw. 

This  author  enumerates  the  following  symptoms  of  a  very  ag- 
gravated form  of  this  disease — inordinate  appetite,  burning 
thirst ;  a  small  spot  on  the  cheek,  or  about  the  lips,  resembling 
an  anthrax,  which  rapidly  increases  in  size,  turns  black,  sepa- 
rates, discharges  an  ichorous  fluid,  and  its  edges  roll  themselves 
up  like  flesh  exposed  to  the  action  of  a  brisk  flre  :  the  flesh  sepa- 
rates from  the  face :  the  bones  become  exposed,  hectic  fever  en- 
sues, and  in  the  course  of  fifteen  or  twenty  days,  death  puts  an 
end  to  the  sufferings  of  the  child.  Delabarre  asserts  that  this 
affection  is  more  common  among  females  than  males,  and  that 
the  bones  of  the  jaw  are  so  much  softened  that  they  may  be 
easily  cut  with  a  knife. 

CAUSES. 

The  disease  seems  to  be  the  result  of  general  debility  or  de- 
fective nutrition  and  a  cachectic  habit  of  body.  It  never  occurs 
among  the  wealthy,  but  is  always  confined  to  children  of  the 
poor  and  destitute,  and  so  far  as  the  author's  observations  ex- 
tend, to  those  who  reside  in  cellars  or  small  and  confined  apart- 
ments. Children  of  scorbutic  habit  seem  to  be  the  most  subject 
to  it.  Delabarre,  however,  says  he  has  met  with  it  in  children 
who  appear  robust,  and  in  other  respects  well.  He  locates  the 
seat  of  the  disease  in  the  organs  of  nutrition,  and  in  the  fluids 
that  are  conveyed  to  them.  The  disposition  of  body  which  gives 
rise  to  it,  he  mentions  as  being  sometimes  innate,  sometimes  the 
result  of  a  want  of  proper  nourishment.  He  does  not  think  it 
arises  from  the  specific  affection  of  any  separate  organ. 

From  the  great  debility  of  all  the  organs  of  the  body,  their 
functions  are  languidly  and  imperfectly  performed.  That  the 
disease  is  determined  by  general  enfeeblement  of  the  functions 


TREATMENT   OF    ULCERATION    OF   THE    GUMS.  473 

of  the  body,  there  is,  we  think,  little  doubt ;  but  whether  it  would 
develop  itself  independently  of  any  local  cause,  is  a  question 
which  we  do  not  feel  ourself  able  satisfactorily  to  answer.  It  is 
not  at  all  improbable,  that  local  irritants  are  the  exciting  cause; 
and  we  are  the  more  inclined  to  this  belief  from  the  fact,  that  in 
all  the  cases  which  have  fallen  under  our  observation,  the  teeth 
were  considerably  decayed,  and  had  previously  given  rise  to 
pain  ;  and  in  some  instances  they  were  coated  with  tartar.  While, 
therefore,  the  character  of  the  aifection  is  determined  by  some 
peculiar  constitutional  tendency  and  general  enfeeblement  of  the 
vital  powers  of  the  body,  it  is  not  .unlikely,  that  local  irritation 
is  the  immediate  cause  of  its  development. 

TREATMENT. 

As  the  treatment  of  this  affection  comes  more  immediately 
within  the  province  of  the  medical  than  of  the  dental  practitioner, 
we  shall  not  dwell  long  upon  the  subject. 

The  local  treatment  should  consist  of  acidulated  and  astrin- 
gent gargles,  and  a  chlorinated  solution  of  lime  or  soda.  The 
ulcerated  parts  may  be  occasionally  touched  with  a  strong  solu- 
tion of  the  nitrate  of  silver,  and  Delabarre  says,  he  has  in  some 
cases,  derived  great  advantage  from  touching  them  with  the 
actual  cautery.  As  soon  as  the  alveolar  process  exfoliates,  it 
should  be  removed.  After  this  takes  place,  a  cure  is  generally 
speedily  effected  under  proper  constitutionaJ  treatment.  This 
last  may  consist  of  mild  alteratives,  a  generous  nutritive  diet, 
consisting  of  succulent  vegetables  ;  and  in  the  absence  of  fever, 
wholesome  meats,  tonics,  and  exercise  in  the  open  air. 

The  author  just  quoted,  with  a  view  to  arouse  the  vitality, 
says  he  has  successfully  employed  the  juice  of  cruciferous  plants^* 
but  with  them  he  unites  opium,  in  order  to  diminish  their  action 
upon  the  digestive  apparatus.  Counter-irritants,  such  as  blisters, 
he  employs  when  necessary  to  remove  irritation  of  some  internal 
organ. 

*  The  general  properties  of  the  cruci/ern  arc  those  of  pungent  stimuli.  They  arc 
used  for  nutritive  condimentary  and  anti-scorbutic  purposes.  They  are  cardamine, 
horse-radish,  common  scurvy-grass,  black  and  white  mustard, 

31 


474  ADHESION    OF    THE    GUMS    TO    THE    CHEEKS. 


ADHESION  OF  THE  GUMS  TO  THE  CHEEKS. 

The  gums  and  inner  walls  of  the  cheeks  sometimes  contract 
adhesions  wliich  interfere  seriously  with  the  functions  of  the 
mouth.  The  aifection  may  be  congenital,  but  in  a  majority  of 
the  cases  it  occurs  subsequently  to  birth.  The  extent  of  the 
adhesion  may  be  small,  or  it  may  occupy  the  gums  of  the  entire 
alveolar  border  of  one  or  both  sides  of  the  mouth,  and  of  one  or 
both  jaws.  Desirabode  relates  the  case  of  a  young  man,  who, 
in  consequence  of  a  venereal  ulcer,  had  his  upper  lip  united  to 
the  gums  of  the  four  incisors  in  such  a  way  as  to  form  a  sort  of 
loop  above  the  teeth,  which  by  the  retraction  of  the  lip  were 
caused  to  project  outward.* 

Adhesion  of  the  gums  to  the  cheeks  or  lips,  results  from 
ulceration  caused  either  by  constitutional  disease  or  local  lesions. 
But  that  it  arises  more  frequently  as  a  consequence  of  the  im- 
moderate use  of  mercury  than  from  any  other  cause,  is  a  univer- 
sally admitted  fact.  The  author  has  met  with  several  cases, 
however,  in  which  the  affection  had  resulted  from  ulceration  of 
the  gums  around  necrosed  temporary  teeth ;  and  of  the  corres- 
ponding wall  of  the  cheek,  caused  by  excoriation  of  the  mucous 
membrane,  produced  by  the  sharp  points  of  the  protruding 
roots.  But  the  extent  of  the  adhesion,  in  cases  of  this  sort,  is 
never  very  considerable. 

The  proper  remedy  is  to  separate  the  parts  which  have  grown 
together  Avith  a  sharp  bistoury.  This  done,  reunion  should  be 
prevented  by  keeping  a  pledget  of  cotton  or  lint  in  the  wound, 
until  the  process  of  cicatrization  is  completed. 

*  Author's  translation  of  Desirabode's  Complete  Elements  of  the  Science  and  Art 
of  the  Dentist,  page  227. 


CHAPTER  THIRD. 

TUMORS  AND  EXCRESCENCES  OF  THE  GUMS  AND 
ALVEOLAR  PROCESSES. 

From  the  gums  and  alveolar  processes,  tumors  and  excres- 
cences of  various  kinds  are  occasionally  developed,  A'"arying  in 
character,  from  a  mere  simple  growth  of  the  gums  to  morbid 
productions  of  a  fungoid,  cartilaginous,  bony  or  scirrhous  nature. 

Some  are  smooth,  others  rough,  and  sometimes  covered  with 
eroding  ulcers;  some  are  bulbous,  with  a  broad  base,  others  are 
attached  by  a  mere  peduncle ;  some  are  soft,  others  are  hard ; 
the  growth  of  some  is  astonishingly  rapid,  that  of  others  is  so 
slow  as  to  be  scarcely  perceptible;  some  are  almost  entirely 
destitute  of  blood-vessels,  others  appear  to  be  almost  wholly 
composed  of  capillaries;  some  are  nearly  destitute  of  sensibility, 
others  are  so  exquisitely  sensitive,  that  the  slightest  touch  pro- 
duces great  pain ;  and  hence  the  name,  noli  me  tangere  (touch 
me  not),  given  to  one  of  these  diseases;  some  are  nearly  white, 
others  have  a  grayish  appearance ;  some  retain  the  natural  color 
of  the  gum,  others  are  of  a  dark  purple  hue.  Finally,  some 
exist  for  years  without  being  attended  with  any  serious  conse- 
quences ;  while  others,  in  a  few  months,  assume  so  aggravated  a 
character  as  to  threaten  the  life  of  the  patient. 

CAUSES. 

Tumors  of  the  gums  seldom  arise  spontaneously.  They  are, 
in  most  instances,  the  result  of  local  irritation,  occasioned  by  the 
presence  of  tartar,  decayed  or  dead  teeth,  or  roots  of  teeth ;  but 
the  character  which  they  assume  is  determined  by  the  state  of 
the  constitutional  health  or  habit  of  body.  Hence  their  great 
variety.  Here,  as  on  other  parts  of  the  body,  the  same  causes 
often  produce  different  effects.  One  that  would  give  rise  to  the 
development  of  a  simple  morbid  growth  of  the  gums  in  a  person 


476  CAUSES  OF  TUMORS  OF  THE  GUMS. 

of  good  health,  might,  in  one  afifected  with  some  constitutional 
vice  or  specific  morbid  tendency,  give  rise  to  a  tumor  of  a  fun- 
goid, cartilaginous,  bony,  or  scirrhous  character. 

It  is  thought  by  some  that  morbid  productions  of  this  kind 
are  occasionally  developed,  independently  of  any  local  cause; 
but  this  opinion  does  not  seem  to  be  well  founded,  and  we  are 
disposed  to  believe  that,  if  all  the  circumstances  conne^^ed  with 
the  history  of  each  case,  especially  the  previous  condition  of  the 
teeth,  could  be  accurately  ascertained,  their  cause  might,  in  most 
instances,  be  traced  to  irritation  of  the  gums,  or  alveolar  mem- 
branes, pi'oduced  by  some  unhealthy  or  crowded  state  of  these 
organs,  or  to  the  presence  of  salivary  calculus. 

Mr.  Listen,  in  his  Practical  Surgery,  remarks:  "Very  many 
of  the  tumors  of  the  jaws  are  traceable  to  faulty  growth  or  posi- 
tion of  the  teeth,  to  diseases  of  their  bodies,  or  to  improperly 
conducted  operations  upon  them."  And,  in  speaking  of  tumors 
of  the  gums,  he  observes:  "They  are  caused  by  decay  of  some 
part  of  one  or  more  teeth,  of  the  crown,  neck,  fang,  or  they 
may  arise  from  their  being  crowded  or  misplaced."  A  crowded 
arrangement  of  the  teeth  is  always  productive  of  more  or  less 
irritation  to  the  alveolo-dental  periosteum. 

We  do  not,  however,  conceive  it  necessary  to  the  production 
of  tumors,  that  any  of  the  causes  here  enumerated  should  exist 
at  the  time  they  make  their  appearance.  The  gums  and  alveoli 
having  been  once  affected,  are  ever  after  more  susceptible  to 
morbid  impressions.  It  is,  therefore,  quite  probable  that  an  un- 
healthy action  is  sometimes  continued  in  them  long  after  the 
cause  that  produced  it  ceases  to  exist;  and  that  this,  favored  by 
a  subsequent  unhealthy  action  of  some  other  part,  or  of  the  sys- 
tem generally,  determines  their  development.  When  we  con- 
sider how  often,  and  almost  constantly,  the  gums  and  alveolar 
periosteum  are  exposed  to  irritation,  from  the  causes  just  men- 
tioned, we  must  admit,  that  this  hypothesis  is  supported  by  a 
high  degree  of  probability.  No  one,  we  think,  will  pretend  to 
deny  that  the  maxillae  and  gums  suffer  more  from  local  irritation 
than  any  of  the  other  parts  of  the  body ;  and  to  this  irritation, 
we  are  firmly  persuaded,  most  of  their  diseases  are  to  be  ascribed. 


TREATMENT    OF   TUMORS    OF   THE    GUMS.  477 


TREATMENT. 

The  most  common  form  of  morbid  growth  met  with  in  the 
mouth  is  that  which  resembles  in  structure  the  gums,  except  that 
it  is  usually  rather  more  vascular.  This  description  of  tumor  is 
always  the  result  of  dental  irritation,  and  usually  disappears 
soon  after  the  removal  of  the  cause. 

In  1828,  the  author  was  consulted  by  a  gentleman  who  had  a 
considerable  enlargement  of  the  gums,  which  had  followed  an 
attempt  to  extract  the  first  superior  molar  of  the  left  side.  In 
the  operation  the  two  buccal  roots  were  fractured  and  left  in 
their  sockets.  For  fifteen  or  twenty  days  after  the  accident,  he 
experienced  considerable  pain  ;  but  at  the  expiration  of  this  pe- 
riod, it  had  entirely  subsided.  About  two  months  after,  how- 
ever, it  was  again  experienced ;  although  the  gum  had  grown 
over  the  roots,  it  was  sore  to  the  touch,  and  soon  began  to  as- 
sume a  bulbous  form,  gradually  increasing  in  size.  At  the  expi- 
ration of  twelve  months,  when  we  saw  the  patient,  the  tumor 
had  attained  the  size  of  a  black  walnut,  and  was  attached  by  a 
broad  base.  As  it  was  situated  immediately  over  the  fractured 
roots  left  in  the  socket,  we  advised  the  removal  of  the  tumor 
previously  to  attempting  their  extraction.  This  he  most  posi- 
tively refused  to  permit,  but  readily  consented  to  the  removal  of 
the  roots. 

In  the  performance  of  this  operation,  about  one-third  of  the 
base  was  cut  away,  and  the  remaining  part  of  the  tumor  sloughed 
off  in  a  few  days. 

Mr.  Fox  relates  the  case  of  a  lady  who  had  an  enlargement 
of  the  gums  that  almost  entirely  filled  up  one  side  of  her  mouth. 
She  first  applied  to  Sir  Astley  Cooper,  who  sent  her  to  Mr.  Fox 
to  have  several  decayed  roots,  at  the  base  of  the  tumor,  extracted, 
before  he  should  attempt  its  extirpation.  The  fangs  being  im- 
bedded in  the  gums,  the  excrescence  was  much  lacerated  in  their 
removal ;  afterwards  it  became  flaccid,  assumed  a  dark  color, 
and  in  a  short  time  sloughed  off.  Thus  a  perfect  cure  was  effected 
without  any  other  operation  than  that  of  the  extraction  of  the 
decayed  roots. 

This  tumor,  it  would  seem,  partook  somewhat  of  a  fungoid 


478  TREATMENT    OF    TUMORS   OF   THE    GUMS. 

character,  and  excrescences  of  this  description  are  usually  more 
difficult  to  cure  than  those  which  consist  of  a  mere  simple  growth 
of  the  gums,  like  the  one  first  noticed.  Although  they  sometimes 
disappear  spontaneously,  on  the  removal  of  the  exciting  cause, 
yet,  in  most  cases,  extirpation  becomes  necessary,  and  even  this 
when  not  performed  in  the  most  perfect  manner,  is  not  always 
successful.  After  the  removal  of  one,  another  has  been  known 
to  spring  up  in  its  place ;  and  thus  several  have  sometimes 
appeared  in  quick  succession. 

Mr.  Hunter  attributes  the  disposition  of  a  tissue  to  reproduce 
excrescences  of  this  kind,  to  a  scirrhous  tendency  of  the  parts 
from  which  they  originate,  but  the  tumor  will  rarely  reappear,  if 
the  diseased  structure  be  completely  removed. 

Mr.  Fox  recommends  that  excrescences  of  this  sort  should  be 
extirpated  by  means  of  ligatures,  with  the  assurance  that  when 
thus  removed,  a  second  operation  is  seldom  necessary.  Excision 
is  often  attended  with  profuse  and  obstinate  hemorrhage,  and, 
on  this  account,  the  operation  recommended  by  him  is,  in  most 
cases,  preferable.  The  base  of  some  tumors,  however,  is  so 
broad,  that  a  ligature  cannot  be  applied  sufficiently  low  to  in- 
clude the  whole  structure.  In  such  cases  we  must  resort  to  ex- 
cision, and  if  the  hemorrhage  cannot  be  stopped  by  compresses 
or  by  the  per-sulphate  of  iron,  the  actual  cautery  may  be  em- 
ployed. 

Mr.  Hunter,  in  treating  of  morbid  growths  of  soft  parts,  ob- 
serves :    "  Arteries  going  to  increased  parts  are  themselves  in- 
creased, and  have  not  the  contractile  power  of  a  sound  artery : 
hence  when  wounded,  they  bleed  more  freely  than  those  that  are- 
in  a  healthy  state." 

The  removal  of  excrescences  of  the  gums  by  means  of  liga- 
tures, not  being  attended  with  so  much  hemorrhage,  and  also 
usually  exterminating  them  more  effectually  than  excision,  de- 
termined Mr.  Fox  in  his  choice  of  this  mode  of  operating.  In 
treating  of  this  subject,  he  remarks  :  "  I  determined,  some  years 
since,  that  if  any  case  of  this  kind  should  ever  come  under  my 
care,  I  would  attempt  the  removal  by  means  of  ligatures.  The 
first  case  in  which  I  was  consulted,  was  a  lady  about  forty  years 
of  age,  who  had  several  of  the  teeth  on  the  right  side  of  the 
upper  jaw  extracted  when  she  was  a  young  Avoman ;  about  five 


I 


TREATMENT  OF  TUMORS  OF  THE  GUMS.        479 

years  before  I  saw  her,  the  gums  covering  the  jaw  where  the 
teeth  had  been  situated,  appeared  to  be  thicker  than  before ; 
they  gradually  increased  in  size  until  a  very  large  tumor  was 
formed ;  it  had  now  become  so  large  as  to  affect  the  speech,  and, 
in  other  respects,  was  extremely  troublesome. 

"  The  lady  was  very  desirous  to  have  it  removed ;  to  effect 
which,  without  incurring  the  danger  of  hemorrhage,  I  employed 
ligatures,  close  to  the  jaw-bone,  through  the  substance  of  the 
tumor,  half  of  which  was  then  included  in  each  ligature.  The 
ligatures  were  tied  just  tightly  enough  to  stop  the  circulation ; 
the  next  day  there  was  a  great  deal  of  inflammation,  which  sub- 
sided in  proportion  as  the  ligatures  began  to  produce  ulceration, 
which,  on  the  fourth  day  was  very  considerable ;  new  ligatures 
were  then  applied ;  on  the  sixth  day  these  were  removed,  and 
others  introduced ;  on  the  eighth,  one  ligature  came  away,  leav- 
ing the  tumor  hanging  only  by  a  small  peduncle ;  this  being  cut 
through  with  a  lancet,  the  whole  was  removed. 

Even  when  the  base  is  large,  the  tumor  may  be  often  success- 
fully removed  by  passing  a  needle,  armed  with  a  double  ligature, 
through  it,  close  to  the  bone,  and  tying  it  on  each  side  suffi- 
ciently tight  to  cut  off  the  circulation  between  it  and  the  general 
system  ;  and  it  should  be  reapplied  as  often  as  it  comes  away, 
until  the  tumor  has  sloughed  off,  when  the  place  should  be 
touched  with  diluted  nitrous  acid  or  with  a  solution  of  nitrate  of 
*ilver. 

Cartilaginous  excrescences  of  the  gums  and  alveolar  processes 
are  comparatively  of  rare  occurrence,  and  are  more  difficult  to 
remove  than  fungous  tumors,  or  those  which  consist  merely  of  a 
preternatural  growth  of  the  gums.  The  hardness  of  their  sub- 
stance is  such,  that,  in  many  cases,  their  removal  by  ligature  is 
impracticable,  and  extirpation  with  the  knife  is,  also,  sometimes, 
exceedingly  difficult  and  tedious.  Besides,  the  operation  of  ex- 
cision is  often  followed  by  obstinate  hemorrhage. 

Ambrose  Pare,  with  no  small  self-gratulation,  talks  of  having 
removed  them  when  they  were  so  large  that  they  came  out  of 
the  mouth,  giving  a  most  hideous  appearance  to  the  face,  and 
when  no  other  surgeon  dared  to  undertake  their  cure,  because  of 
the  lividity  of  their  color.  "  This  lividity,"  says  he,  "I  did  not 
fear,  but  I  had  the  boldness  to  cut  and  even  to  cauterize  the 
tumors  until  the  disease  was  entirely  cured." 


480  TREATMENT    OF   TUMORS    OF   THE   GUMS. 

Jourdain,  in  speaking  of  cartilaginous  excrescences,  remarks  : 
"About  thirty-six  years  ago,  I  was  called,  with  Allertius  Bar- 
ingue,  surgeon,  to  see  a  woman  that  had  a  tumor  of  a  large  size 
situated  on  the  gum  of  the  molar  teeth.  It  occasioned  her  mouth 
to  be  drawn  to  the  opposite  side  of  her  face,  when  she  was  seized 
with  soasms.  We  advised  her  not  to  delay  too  long  in  having 
it  removed ;  to  this  she  would  not  consent,  but,  in  a  short  time, 
finding  that  the  excrescence  increased  so  fast,  and  in  such  a 
manner  that  it  hindered  her  from  taking  food,  she  changed  her 
mind.  The  tumor  was  embraced  with  a  brass  wire,  which  we 
tightened  every  day.  The  excrescence,  receiving  nothing  now 
to  augment  its  growth,  fell,  and,  upon  examination,  we  found 
that  it  was  altogether  cartilaginous,"* 

Dr.  Fitch  quotes  a  case  from  Luzitanus,  in  which  the  opera- 
tion for  the  removal  of  the  tumor  was  followed  by  a  fatal  hemor- 
rhage. The  tumor  is  described  as  being  about  half  the  size  of  a 
hen's  egg,  exhaling  a  fetid  odor,  and  being  very  painful.  He 
also  mentions  a  case  of  somewhat  similar  character,  that  came 
under  his  own  observation.  "  The  tumor  occupied  the  space  of 
the  four  incisor  teeth  of  the  upper  jaw.  The  teeth  were  all 
carious.  I  extracted  them.  The  tumor  had  four  fistulous  open- 
ings, one  to  each  tooth,  and  each  discharging  a  fetid  humor. 
With  the  actual  caiitery  well  heated  in  fire  and  double-edged,  I 
made  but  one  wound  of  the  four  fistulous  openings,  and  touched 
the  bone  that  was  carious ;  this  was  repeated  several  times  in  the 
space  of  three  months.  The  tumor  diminished  in  proportion  as 
the  exfoliations  were  made  ;  and  the  patient  was  cured  near  the 
end  of  the  fourth  month. "f 

When  the  base  of  the  tumor  is  very  broad,  and  the  bone  be- 
neath carious,  as  in  the  case  described  by  Dr.  Fitch,  the  actual 
cautery  is,  without  doubt,  a  sure  remedy,  because  it  is  obvious 
that  until  the  diseased  bone  exfoliates,  a  cure  can  never  be 
effected.     But  under  no  circumstances  is  the  use  of  it  advisable. 

Tumors  originating  in  the  alveolar  processes  or  periosteum, 
are  generally  of  an  osteo-sarcomatous,  or  cartilaginous  character. 
Their  removal  in  either  case  is  more  difficult  than  that  of  fung- 
ous excrescence ;  and  their  cure  less  certain. 

"-■■  Jourdain,  tome.  2,  p.  334. 

t  Fitch's  Dental  Surgery,  p.  237. 


TREATMENT    OF   TUMORS    OF   THE    GUMS.  481 

Mr.  Bell  has  given  the  history  of  two  cases  of  tumors  of  the 
gums  and  alveolar  processes.  One  of  them,  however,  he  says, 
had  no  connection  with  the  alveolar  processes,  and  the  other 
succeeded  to  an  attack  of  the  tooth-ache  which  had  lasted  several 
months. 

A  case  of  osteo-sarcomatous  tumor,  occasioned  by  diseased 
teeth,  is  recorded  by  Bordenave.  Sir  Astley  Cooper  gives  the 
history  of  two  cases  of  a  like  nature.  In  one,  the  tumor  origi- 
nated in  the  alveolar  cavities,  and  as  it  increased,  displaced  the 
teeth  ;  in  the  other  case  the  tumor  was  produced  by  diseased 
teeth.  Dr.  Gibson,  also,  mentions  a  case  of  osteo-sarcomatous 
tumor,  which,  "  according  to  the  patient's  account,  first  appeared 
seven  months  before,  in  the  form  of  a  small  lump,  seated  in  the 
gum  above  the  canine  tooth." 

In  the  treatment  of  tumors  originating  from  the  gums  or  alve- 
olar processes,  or  from  both,  much  depends  on  their  character 
and  the  constitutional  symptoms  accompanying  them.  Some 
may  be  dispersed  by  simply  extracting  a  decayed  tooth  or  root ; 
others  will  require  extirpation,  and,  in  some  instances,  even  this 
will  not  avail.  In  short,  the  treatment  must  be  varied  to  suit 
the  respective  circumstances  of  the  case. 

It  sometimes  happens,  when  an  operation  has  been  performed 
successfully,  so  far  as  regards  the  local  disease,  that  the  lungs, 
or  some  other  vital  organ,  becomes  affected.  To  prevent  this, 
it  is  often  necessary  to  get  up,  by  means  of  a  seton  or  issue, 
counter  irritation  in  some  neighboring  part.  Without  this  pre- 
caution, the  life  of  the  patient  would  often  be  put  in  as  great 
danger  as  that  from  which  it  had  escaped  by  the  removal  of  the 
local  disease. 

On  the  extirpation  of  the  fungous  exostosis,  or  osteo-sarcoma, 
Sir  Astley  Cooper  observes :  "  Amputation  after  constitutional 
means  have  been  employed,  and  the  continuance  of  these  means 
after  the  operation,  hold  out  the  chief  hopes  of  safety ;  for  am- 
putation without  these,  will  do  no  more  than  avert  the  blow  for 
a  season." 

These  remarks  will  be  found  applicable  to  the  treatment  of 
the  same  description  of  disease,  in  whatever  part  of  the  body  it 
may  be  situated.  The  constitutional  symptoms  should  never  be 
disregarded. 


CHAPTER     FOURTH. 

ALVEOLAR  ABSCESS. 

As  most  of  the  phenomena  attending  the  formation  of  alveolar 
abscess  were  noticed  in  the  chapter  on  tooth-ache,  it  will  not  be 
necessary,  in  this  place,  to  dwell  upon  them  at  much  length. 
The  periosteum  of  a  tooth  having  become  the  seat  of  acute  in- 
flammation, plastic  lymph  is  eflused  at  the  extremity  of  the  root. 
This  is  condensed  into  a  sac  or  cyst,  which  closely  embraces  the 
root  near  its  apex,  and  as  suppuration  takes  place,  pus  is  formed 
in  its  centre.  The  inflammation,  in  the  meantime,  having  ex- 
tended to  the  gums  and  neighboring  parts,  they  swell  and  be- 
come painful,  and  as  the  pus  accumulates  in  the  sac,  it  distends 
and  presses  upon  the  surrounding  walls  of  the  alveolus,  which 
by  a  sort  of  chemico-vital  process,  are  gradually  broken  down. 
By  this  means  an  opening  is  ultimately  made  through  one  side 
of  the  socket,  when  the  pus,  coming  in  contact  with  the  investing 
soft  structures,  presses  upon  them  and  causes  their  absorption. 
Thus  an  outlet  is  efiected  for  the  escape  of  the  accumulated 
matter. 

The  opening  which  gives  egress  to  the  pus,  is  usually  in  the 
gum  opposite  the  extremity  of  the  root,  but  the  matter  may 
escape  from  some  other  and  more  remote  point.  It  may  make 
for  itself  an  opening  through  the  cheek  or  through  the  base  of 
the  lower  jaw,  and  be  discharged  externally  ;  or  it  may  pass  up 
into  the  maxillary  sinus,  or  through  the  nasal  plates  of  the 
superior  maxilla,  or  form  a  passage  between  the  two  plates  of 
the  bone,  and  escape  from  the  centre  of  the  roof  of  the  mouth. 

The  formation  of  abscess  in  the  alveolus  of  an  inferior  dens 
sapientise,  is  sometimes  attended  with  inflammation  and  swelling 
of  the  tonsils  and  of  the  muscles  of  the  cheek  and  neck.  The 
author  has  known  trismus  to  result  from  this  cause. 

The  pain  attending  the  formation  of  alveolar  abscess,  is  deep 
seated,  throbbing,  and  often  so  excruciating  as  to  be  almost  in- 


ALVEOLAR    ABSCESS.  483 

supportable.  But  as  soon  as  suppuration  takes  place,  it  loses  its 
severity,  and  with  the  escape  of  the  pus  nearly  or  altogether 
ceases  ;  but  the  tooth,  from  the  thickened  condition  of  the  alveolo- 
dental  periosteum,  particularly  at  the  apex  of  the  root,  often 
remains  sore  and  sensitive  to  the  touch  for  several  days.  The 
energies  of  the  disease,  however,  having  been  expended,  the  se- 
cretion of  the  pus,  in  the  majority  of  cases,  wholly  ceases,  and 
the  opening  in  the  gums  closes.  From  the  increased  suscepti- 
bility in  the  alveolo-dental  periosteum  to  morbid  impression, 
occasioned  by  the  presence  of  a  tooth  deprived  of  a  large  portion 
of  its  vitality,  a  recurrence  of  the  inflammation  is  liable  to  take 
place,  when  pus  will  be  again  formed  and  the  passage  for  its 
escape  re-established.  But  the  pain  attending  any  subsequent 
attack,  is  seldom  so  severe  as  in  the  first  instance.  ^ 

There  are  some  cases,  however,  in  which  the  inflammation,  in- 
stead of  subsidino;  altogether,  degenerates  into  a  chronic  form. 
In  this  case,  the  sac  at  the  extremity  of  the  root  continues  to 
secrete  pus,  though  the  quantity  is  usually  small,  and  the  open- 
ing in  the  gums  remains  unclosed. 

In  the  extraction  of  a  tooth  which  has  given  rise  to  the  forma- 
tion of  abscess,  the  sac  is  often  brought 

•  1     •         rn  ,     •  ,  .   1      ^  •       Fi«-  162.         Fig.  163. 

away  with  it.     Two  teeth  in  which  this 

had  happened,  taken  from  the  upper  jaw, 
one  a  cuspid,  and  the  other  a  first  molar, 
are  represented  in  the  accompanying  cuts, 
Figs.  162  and  163.  In  the  case  of  the 
molar,  the  sac  is  attached  to  the  palatine 
root.  Both  of  these  teeth  were  extracted 
previously  to  the  formation  of  an  external 
opening  for  the  escape  of  the  matter. 

The  time  required  for  the  formation  of  alveolar  abscess,  varies 
from  three  to  ten  or  fifteen  days,  according  to  the  violence  of 
the  inflammation.  But  a  collection  of  pus  may  be  detected  by 
fluctuation  under  the  .finger,  if  applied  to  the  tumefied  gum,  one 
or  two  days  before  an  external  opening  is  spontaneously  formed 
for  its  escape. 

The  inflammation  and  pain  attending  the  formation  of  abscess, 
in  the  socket  of  a  tooth,  often  give  rise  to  general  febrile  symp- 
toms, headache  and  constipation  of  the  bowels. 


484  TREATMENT    OF   ALVEOLAR    ABSCESS. 


CAUSES. 

The  immediate  cause  of  alveolai-  abscess  is  inflammation  of  the 
alvcolo-dental  periosteum,  and  this  may  arise  from  inflammation 
and  suppuration  of  the  lining  membrane  and  pulp ;  or  from  an 
accumulation  of  purulent  matter  at  the  extremity  of  the  root, 
the  egress  of  which,  through  the  natural  opening,  has  been  pre- 
vented. It  may  also  be  produced  by  mechanical  violence,  the 
irritation  of  a  dead  tooth,  or  by  the  presence  of  a  portion  of  a 
gold  filling  forced  through  the  fang  of  a  tooth  ;  as  in  the  follow- 
ing case  related  to  the  author  by  his  friend  Prof.  C.  Johnston  of 
Baltimore.  A  medical  gentleman  called  upon  a  dentist  of  this 
city  to  treat  a  left  first  upper  molar  affected  with  caries.  It  was 
decided  to  remove  the  diseased  pulp  and  introduce  a  fang  filling, 
and  accordingly  the  operation  was  undertaken  ;  but  in  packing 
the  first  pellet  in  an  external  fang,  the  instrument  suddenly 
slipped  forward,  and  from  this  circumstance  as  well  as  from  the 
pain,  it  became  evident  that  the  gold  had  passed  out  of  the  tooth. 
For  nine  months  afterwards  no  inconvenience  followed  the  ope- 
ration, which  was  otherwise  satisfactorily  completed ;  when 
suddenly  there  appeared  a  soreness  of  the  gum  of  the  same  tooth. 
Soon  after  a  small  tumor  arose  upon  the  face,  half  an  inch  above 
the  left  angle  of  the  mouth,  maturated,  and  burst  spontaneously, 
discharging  the  erring  pellet  of  gold.  In  a  few  days  the  open- 
ing closed,  and  a  perfect  cure  resulted. 

TREATMENT. 

The  treatment  of  alveolar  abscess  should  be  preventive,  rather 
than  curative,  for  it  rarely  happens,  after  it  has  occurred,  that 
the  integrity  of  the  parts  is  so  perfectly  restored,  as  to  prevent 
a  recurrence  of  the  affection.  Although  the  secretion  of  pus 
may  cease  for  a  time,  and  the  opening  in  the  gums  become  ob- 
literated, the  tooth  being  deprived  of  a  large  portion  of  its  vital- 
ity, is  liable,  whenever  the  excitability  of  the  alveolo-dcntal 
periosteum  is  increased  by  any  derangement  of  the  general  sys- 
tem, to  give  rise  to  a  recurrence  of  the  disease.  The  formation 
of  abscess,  therefore,  should,  if  possible,  be  prevented  by  the  use 


TREATMENT    OF    ALVEOLAR    ABSCESS.  485 

of  saline  cathartics,  the  application  of  leeches  to  the  gums,  and 
a  cooling  regimen.  By  prompt  antiphlogistic  treatment  the  in- 
flammation may  sometimes  be  arrested.  But  should  these  means 
fail  to  prevent  the  formation  of  pus,  the  tooth,  unless  its  reten- 
tion is  called  for  by  some  peculiar  necessity,  should  at  once  be 
removed.  If,  however,  as  is  often  the  case,  the  patient  will  not 
submit  to  the  operation,  the  escape  of  the  pus  through  the  gum 
should  be  promoted  by  warm  fomentations  to  the  mouth.  As  soon 
as  fluctuation  can  be  perceived  by  applying  the  finger  to  the 
tumefied  gum,  an  opening  may  be  made  with  a  sharp  lancet  for 
the  escape  of  the  matter.  After  this  has  discharged  itself,  the 
swelling  of  the  gums  and  neighboring  parts  soon  subside. 

The  application  of  fomentations  and  emollient  poultices  ex- 
ternally, are  rarely  productive  of  any  advantage,  and  may  do 
harm  by  promoting  the  discharge  of  matter  through  the  cheek 
or  lower  part  of  the  face.  When  this  occurs,  a  depression  with 
puckering  of  the  skin  is  apt  to  remain  after  the  escape  of  pus 
through  the  opening  ceases  and  the  orifice  has  closed,  causing 
disfiguration  of  the  face. 

A  very  singular  case  of  fistulous  opening  through  the  external 
integument  is  mentioned  by  Mr.  Thomas  Bell.  It  had  resulted 
from  an  abscess  in  the  socket  of  the  right  inferior  dens  sapientiiB, 
and  the  discharge  of  matter  had  been  kept  up  for  two  years 
before  he  saw  the  patient.  "At  this  time,"  says  Mr.  B.,  "a 
funnel-shaped  depression  existed  in  the  skin,  which  could  be 
seen  to  the  depth  of  nearly  three-quarters  of  an  inch,  and  a 
small  probe  could  be  passed  through  it  into  the  sac  of  the 
abscess,  underneath  the  root  of  the  tooth.  The  abscess  had 
now  remained  open  for  two  years,  during  the  latter  part  of  which 
time,  the  parts  had  been  in  the  state  I  have  described.  I  re- 
moved the  tooth,  and,  as  I  anticipated,  no  further  secretion  of 
pus  took  place ;  but  so  perfectly  had  the  communication  been 
established,  that  when  the  gum  healed,  it  left  by  its  contraction 
a  fistulous  opening,  through  which  a  portion  of  any  fluid  received 
into  the  mouth  passed  readily  to  the  outside  of  the  cheek ;  and 
I  could,  by  carefully  introducing  a  fine  probe,  pass  it  completely 
through  the  passage.  So  free  in  fact  was  the  communication, 
that  some  of  the  hairs  of  the  whiskers,  with  which  the  external 
portion  of  the  depression  was  filled,  grew  through  the  internal 
opening,  and  appeared  in  the  mouth. 


486  TREATMENT    OF    ALVEOLAR    ABSCESS. 

"  I  passed  through  it  a  very  fine  knife,  resembling  the  couch- 
ing-needle,  and  removed,  as  perfectly  as  possible,  a  circular 
portion  of  the  parietes  of  the  tube  toward  the  gum ;  but  failed 
in  this,  and  several  other  attempts,  to  produce  a  union.  It  was, 
therefore,  resolved  that  the  whole  parietes  of  the  depression 
should  be  removed,  extending  the  incision  as  far  internally  as 
possible;  and  the  integuments  thus  brought  together  as  a  simple 
wound.  In  consequence,  however,  of  the  suppuration  of  a  small 
gland  in  the  immediate  neighborhood,  the  operation  was  deferred 
until  that  should  have  been  dispersed;  it,  therefore,  remains  at 
present  in  the  state  in  which  I  have  described  it." 

It  rarely  happens,  however,  that  anything  more  is  necessary 
for  the  cure  of  the  external  opening  than  the  extraction  of  the 
tooth  which  had  given  rise  to  the  formation  of  the  abscess. 
The  author  has  been  consulted  in  many  cases,  and  has  never 
found  it  necessary  to  resort  to  other  means;  but  should  the 
external  opening  remain,  the  wall  of  the  tube  and  depression 
may  be  removed  in  the  manner  just  described. 

The  formation  of  an  abscess  in  the  alveolus  of  a  lower  wisdom 
tooth,  is  sometimes  productive  of  very  serious  and  even  alarming 
consequences.  The  following  is  one  of  several  similar  cases 
which  have  fallen  under  the  observation  of  the  author. 

In  1832,  he  was  sent  for  in  great  haste  to  visit  a  physician 
who  resided  thirty  miles  in  the  country.  He  had  been  attacked 
two  weeks  before  with  severe  pain  in  the  left  dens  sapientiae  of 
the  lower  jaw.  At  the  expiration  of  three  or  four  days,  a  phy- 
sician was  called  in,  who  made  several  unsuccessful  attempts  to 
extract  the  tooth. 

The  inflammation  now  extended  rapidly  to  the  fauces,  tonsils 
and  muscles  of  the  jaw  and  face.  Obstructed  deglutition  and  a 
constant  fever  supervened,  upon  which  repeated  blood-lettings, 
cathartics  and  fomentations,  applied  to  the  face,  had  little  eifect. 
His  respiration  was  difficult,  and  the  muscles  of  his  jaws  soon 
became  so  rigid  and  firmly  contracted  that  his  mouth  could  not 
be  opened. 

This  was  the  condition  of  the  patient  when  the  author  first 
saw  him,  which  was  the  morning  of  the  day  following  the  one 
on  which  he  was  sent  for.  In  addition  to  the  treatment  which 
had   previously  been   pursued,  an  injection  with  tAvo  grains  of 


TREATMENT    OF    ALVEOLAR    ABSCESS.  487 

emetic  tartar  was  administered.  About  seven  o'clock  in  the 
evening,  the  fever  was  succeeded  by  alternate  paroxysms  of  cold 
and  heat.  An  effort  was  now  made  to  force  open  his  mouth 
with  a  wooden  wedge.  This  was  partially  successful,  but  his 
teeth  could  not  be  forced  asunder  sufficiently  to  admit  of  the  in- 
troduction of  the  smallest  sized  tooth-forceps.  But  while  his 
jaws  were  thus  partially  separated,  he  attempted  to  swallow  some 
warm  tea;  in  the  effort  an  abscess  burst  and  discharged  nearly 
a  tablespoonful  of  pus  from  his  mouth,  and  it  was  supposed  that 
double  that  quantity  passed  down  into  his  stomach.  This  gave 
immediate  relief,  but  it  was  not  until  about  three  o'clock  in  the 
afternoon  of  the  next  day  that  his  jaws  could  be  forced  apart 
sufficiently  to  permit  the  extraction  of  the  tooth  which  had 
caused  the  trouble.  To  the  roots  of  this,  which  Avere  united, 
there  was  attached  a  sac  about  the  size  of  a  large  pea,  filled 
with  pus.  The  patient  recovered  rapidly,  and  in  a  few  days  was 
quite  well. 

The  following  is  the  most  singular  case  of  alveolar  abscess 
which  has  ever  fallen  under  the  observation  of  the  writer:  The 
subject  was  a  lady  about  thirty  years  of  age.  She  had  been 
troubled  with  a  dripping  of  pus  from  behind  the  curtain  of  the 
palate  for  about  twelve  months,  and  becoming  somewhat  alarmed 
at  its  continuance,  she  called  the  attention  of  her  family  physi- 
cian, Professor  Bond,  to  it,  who  carefully  examined  the  case,  and 
endeavored  to  ascertain  the  place  from  whence  the  matter  came. 
He  soon  satisfied  himself  that  it  was  from  the  socket  of  a  dis- 
eased tooth.  Upon  passing  his  finger  around  on  the  gums  cov- 
ering the  superior  alveolar  border,  he  discovered  a  protuberance 
over  the  root  of  each  upper  central  incisor,  nearly  as  large  as  a 
hazel-nut.  This  tended  to  confirm  the  opinion  which  he  had 
formed  as  to  the  source  from  whence  the  matter  came,  and  he 
requested  us  to  visit  the  lady  with  him,  which  we  did  on  the  fol- 
lowing day.  On  examining  the  case,  we  advised  the  immediate 
removal  of  the  affected  teeth,  and  the  more  strongly  as  they 
were  found  to  be  in  a  necrosed  condition. 

The  lady  readily  consented  to  the  operation,  which  was  per- 
formed on  the  following  day.  The  discharge  of  matter  from 
behind  the  curtain  of  the  palate  immediately  ceased,  and  the 
patient  was  relieved  from  an  affection  which  had  been  a  source 


488  TREATMENT    OF    ALVEOLAR    ABSCESS. 

of  great  annoyance.  The  pus  from  the  abscess,  in  this  case, 
instead  of  passing  out  through  the  nasal  phites  of  the  superior 
maxilla,  passed  back  over  the  roof  of  the  mouth,  and  escaped 
in  the  manner  described. 

The  author  Avas  lately  consulted  in  a  case  of  a  similar  charac- 
ter to  the  one  last  noticed.  The  pus  had  found  its  way  from 
the  socket  of  a  first  superior  molar  to  about  the  centre  of  the 
palatine  arch,  thence  passed  up  into  the  posterior  nares,  and  was 
discharged  from  behind  the  velum  palati. 

Inflammation  of  the  investing  membrane  of  the  roots  of  an 
inferior  dens  sapiential  may  produce  equally  serious  effects,  with- 
out occasioning  the  formation  of  an  abscess  in  the  alveolus.  The 
eruption  of  these  teeth  are  sometimes  attended  with  like  conse- 
quences. The  irritation  has,  in  some  instances,  extended  to 
the  lungs,  and  even  been,  in  decidedly  consumptive  persons,  the 
exciting  cause  of  consumption. 

The  occurrence  of  alveolar  abscess  in  the  socket  of  a  tempo- 
rary tooth  is  often  followed  by  exfoliation  of  the  sockets  of  sev- 
eral teeth,  and  sometimes  of  considerable  portions  of  the  jaw- 
bone, seriously  injuring  the  rudiments  of  the  permanent  teeth, 
and  sometimes  causing  their  destruction.  The  author  saw  a 
case,  a  few  years  since,  in  which  an  abscess  of  the  alveolus  of 
the  first  lower  temporary  molar  had  occasioned  exfoliation  of  the 
sockets  of  a  cuspid  and  tAVO  molars.  About  one-half  of  the 
alveolar  cells  of  the  two  bicuspids  and  the  cuspid  of  the  second 
set  were  also  exfoliated,  thus  leaving  their  imperfectly  formed 
crowns  entirely  exposed. 

When  the  inflammation  of  the  alveolo-dental  periosteum  re- 
sults from  inflammation  of  the  pulp  and  lining  membrane,  the 
formation  of  abscess  may  be  prevented  by  the  prompt  destruc- 
tion of  the  latter  with  arsenious  acid,  cobalt  or  chloride  of  zinc. 
If  any  attempt  is  to  be  made  to  secure  the  preservation  of  the 
tooth,  this  should  be  promptly  done,  as  the  chances  of  success 
are  always  greater  previously  to  the  formation  of  an  abscess  than 
afterward.  But  for  a  description  of  the  treatment  in  such 
cases,  the  reader  is  referred  to  the  chapter  on  filling  the  pulp- 
cavities  and  roots  of  teeth. 


CHAPTER     FIFTH. 

NECROSIS  AND  EXFOLIATION  OF  THE  ALVEOLAR  PRO- 
CESSES. 

The  alveolar  processes,  as  well  as  other  osseous  structures,  are 
liable  to  necrosis  or  loss  of  vitality.  When  their  connection 
with  the  periosteum — the  source  from  whence  they  derive  their 
nourishment  and  vitality — is  destroyed,  death  follows  as  a  neces- 
sary consequence.  The  loss  of  vitality  may  be  confined  to  the 
socket  of  a  single  tooth,  but  more  frequently  it  extends  to  several, 
and  sometimes  to  the  entire  alveolar  border,  occasionally  includ- 
ing a  part  or  the  whole  of  the  jaw.  It  may  occur  in  either  jaw, 
but  it  is  more  liable  to  take  place  in  the  lower  than  the  upper. 
When  confined  to  the  alveoli,  the  dead  part  is  never  replaced 
with  new  bone,  but  examples  are  on  record  of  the  regeneration 
of  a  part,  and  even  the  whole  of  the  lower  jaw.  It  is,  however, 
denied  by  some,  that  the  loss  of  any  portion  of  this  bone  is  ever 
replaced  with  true  osseous  structure. 

When  one  or  more  of  the  sockets  of  the  teeth  lose  their  vitality, 
nature  exerts  all  her  energies  to  separate  the  dead  from  the  liv- 
ing bone  ;  this  process,  technically  termed  exfoliation,  is  supposed 
by  some  to  consist  in  a  sort  of  suppurative  inflammation,  but 
there  is  reason  to  believe  it  is  effected  by  the  action  of  a  corro- 
sive fluid  poured  out  from  the  fungous  granulations  of  the  living 
bone  in  immediate  contact  with  the  necrosed  part.  During  the 
process  of  exfoliation,  a  thin  acrid  matter  is  discharged  from  one 
or  more  fistulous  openings  through  the  gums  or  from  between 
them  and  the  necks  of  the  teeth  ;  the  gums  having  lost  their  con- 
nection with  the  necrosed  bone,  become  soft  and  spongy,  and 
assume  a  dark  purple  'appearance,  are  preternaturally  sensitive 
to  the  touch,  and  bleed  from  the  most  trifling  injury. 

In  the  admirable  work  of  Mr.  Fox,  on  the  Natural  History 
and  Diseases  of  the  Teeth,  there  are  two  engravings  of  exfoliated 
alveolar  processes.  The  first  represents  the  alveoli  of  a  central 
32 


490        NECROSIS  OF  THE  ALVEOLAR  PROCESSES. 

and  lateral  incisor  and  that  of  the  left  cuspid,  with  a  portion  of 
the  maxilla,  extending  about  five-eighths  of  an  inch  above  the 
apex  of  the  roots  of  the  last  mentioned  tooth.  The  subject  in 
this  case  was  a  gentleman  whose  left  lateral  incisor  became 
carious ;  inflammation  and  pain  ensued,  together  with  swelling 
of  the  gums  and  lip.  Instead  of  consulting  a  physician,  he  ap- 
plied poultices  to  his  face,  until  suppuration  in  the  alveolus  took 
place,  causing  the  formation  of  an  external  opening  through  the 
gums  for  the  discharge  of  the  matter.  After  his  mouth  had  re- 
mained for  some  time  in  this  condition,  he  applied  to  Mr.  Fox, 
who,  upon  examination,  found  that  not  only  had  the  decayed 
tooth  become  loose,  but  also  one  on  each  side  of  it.  The  first 
he  extracted,  and  discovered  that  the  alveolus,  from  the  de- 
struction of  its  periosteum,  was  quite  rough.  The  adjoining 
teeth,  still  continuing  loose,  were  in  a  few  weeks  removed,  and 
the  slight  force  that  was  applied,  brought  with  them  the  alveolar 
processes  of  the  whole  of  the  three  teeth,  and  also  a  considerable 
portion  of  the  jaw-bone.  The  other  engraving  represents  an  in- 
ferior molar  and  two  bicuspids,  with  their  sockets  and  a  very 
large  piece  of  jaw-bone.  The  necrosis  and  exfoliation  in  this 
case,  as  in  the  other,  was  produced  by  alveolar  abscess. 

The  author  has  met  with  several  very  similar  cases,  though  all 
were  not  produced  by  the  same  cause,  and  he  has  several  speci- 
mens in  his  possession,  two  of  which  were  presented  to  him  by 
his  late  brother,  Dr.  John  Harris. 

The  author  has  met  with  two  cases  of  necrosis  and  exfoliation 
of  the  alveolar  processes,  which  are  worthy  of  special  notice. 
The  subject  of  the  first  case,  was  a  gentleman  of  a  strumous 
habit,  about  thirty  years  of  age ;  the  necrosis  and  exfoliation 
extended  to  the  sockets  of  all  the  teeth  in  the  upper  jaw.  In 
May,  1851,  he  had  the  nerve  destroyed  in  the  second  bicuspid, 
on  the  right  side  of  the  superior  maxilla.  We  believe  it  was 
afterward  removed,  and  the  pulp-cavity  and  root  filled.  About 
six  weeks  after,  as  nearly  as  we  could  ascertain,  the  socket  of 
the  tooth  became  slightly  painful,  but  as  his  suffering  was  not 
constant,  he  supposed  it  would  soon  cease.  The  pain,  ultimately, 
however,  began  to  increase,  and  by  the  latter  part  of  the  follow- 
ing September  was  so  severe,  and  attended  by  so  much  consti- 
tutional disturbance,  that  he  was  induced  to  consult  a  physician. 


NECROSIS  OF  THE  ALVEOLAR  PROCESSES.        491 

After  having  been  under  medical  treatment  for  about  two  weeks, 
the  author  was  requested  by  tlie  medical  attendant  to  see  him. 
The  affected  tooth  was  found  to  be  loose,  and  its  socket  in  a 
necrosed  condition ;  inflammation  had  extended  to  every  part  of 
the  alveolar  border ;  the  gums  were  very  much  swollen,  and 
nearly  all  the  teeth  sensitive  to  the  touch.  As  the  patient  was 
laboring  under  considerable  cerebral  derangement,  and  as  no 
advantage  could  be  derived  from  the  removal  of  the  tooth  at  this 
time,  it  was  deemed  advisable  to  let  it  remain  until  exfoliation 
of  the  necrosed  socket  should  take  place. 

Without  going  into  a  detailed  description  of  the  local  and 
constitutional  treatment  subsequently  pursued,  it  will  be  suffi- 
cient to  state  that  necrosis  extended  to  the  sockets  of  all  the 
other  teeth,  except  those  of  the  second  and  third  molars  on  each 
side  of  the  mouth.  In  the  course  of  about  two  months,  twelve 
teeth,  together  with  their  exfoliated  sockets,  and  several  large 
pieces  of  the  maxillary  bone  were  removed.  It  was  hoped 
that  the  disease  would  stop  here,  but  in  three  or  four  weeks 
the  four  remaining  molars  became  very  sore  to  the  touch, 
and  as  purulent  matter  began  to  be  discharged  from  their 
sockets,  it  became  necessary  to  remove  them.  Several  small 
pieces  of  bone  were  exfoliated  after  the  last  operation,  but  at 
the  expiration  of  about  four  months  from  this  time  his  mouth 
was  sufficiently  restored  to  enable  him  to  wear  a  temporary  set 
of  artificial  teeth. 

The  subject  of  the  second  case  was  a  lady  of  a  cachectic  habit, 
about  thirty-five  years  of  age.  The  necrosis  resulted  from  in- 
flammation   of    the    alveolo-dental    peri- 

Fig.  104. 

osteum,  occasioned  by  irritation  pro- 
duced by  the  roots  of  the  four  upper  in- 
cisors, upon  which  pivot  teeth  had  been 
placed,  which,  however,  had  been  removed 
some  two  or  three  weeks  before  the  author 
saw  the  patient.    At  this  time  the  necrosis 

had  extended  not  only  to  the  sockets  of  these  teeth,  but  also  up 
to  the  nasal  crest  of  the  maxillary  bone,  and  the  process  of  ex- 
foliation had  already  proceeded  so  far,  that  he  was  enabled  to 
remove  the  entire  piece,  the  appearance  of  which  is  rei)resented 
in  Fig.  164.  In  July,  1852,  a  few  weeks  after  the  removal  of 
this  piece,  he  again  saw  the  patient,  and,  on  examination,  found 


Fig.  165. 


492      TREATMENT  OF  NECROSIS  OF  THE  ALVEOLI. 

a  large  portion  of  the  palatine  plate  of  the  bone  in  a  necrosed 
state,  but  the  process  of  separation  had  not  yet  proceeded  far 
enough  to  enable  him  to  remove  it. 

The  accompanying  engraving,  made  from  a  drawing  fur- 
nished the  author  by  Dr. 
Maynard,  represents  a  case 
of  necrosis  and  exfoliation 
of  a  portion  of  the  outer 
wall  of  the  alveolar  ridge,  and 
the  consequent  protrusion  of 
the  roots  of  the  teeth  on  one 
side  of  the  mouth.  The  only  facts  which  Dr.  Maynard  had  been 
able  to  procure  in  relation  to  this  case  were  contained  in  the 
patient's  statement:  "That  in  1818  he  took  a  cold,  which  set- 
tled in  his  upper  jaw,  and  a  large  piece  of  the  jaw-bone  came 
away."  The  cast  from  which  the  drawing  was  made  was  taken 
in  1840;  at  which  time  the  doctor  cut  off  the  apices  of  several 
fangs  which  projected  from  the  gums. 

CAUSES. 

The  immediate  cause  of  necrosis  is  the  death  of  the  perios- 
teum, occasioned  by  inflammation.  The  cause  of  this,  as  has 
already  been  shown,  is,  in  a  large  majority  of  the  cases,  dental 
irritation.  Necrosis  of  the  alveolar  process  occurs  very  fre- 
quently while  the  system  is  under  the  influence  of  mercurial 
medicines,  and  during  bilious  and  inflammatory  fevers,  and  cer- 
tain other  constitutional  diseases,  as  syphilis,  small-pox,  etc.  It 
may  also  result  from  mechanical  injuries. 

TREATMENT. 

In  the  treatment  of  cases  of  this  kind,  little  can  be  done.  As 
soon,  however,  as  the  dead  portions  of  bone  become  separated  from 
the  living,  and  can  be  easily  removed,  they  should  be  taken 
away  with  a  pair  of  forceps.  To  correct  the  off"ensive  odor  and 
disagreeable  taste  occasioned  by  the  constant  discharge  of  fetid 
matter,  a  wash  of  dilute  chlorinated  soda,  or  of  the  tincture  of 
myrrh,  may  be  employed ;  but  for  any  other  purpose  than  this, 
we  have  not  been  able  to  perceive  that  local  applications  were  of 
much  advantage.  Should  constitutional  symptoms  supervene, 
tonics  and  a  generous  diet  may  be  recommended. 


CHAPTER   SIXTH. 
GRADUAL  DESTRUCTION  OF  THE  ALVEOLAR  PROCESSES. 

While  treating  of  inflammation  and  tumefaction  of  the  gums, 
the  author  adverted  to  the  wasting  of  the  sockets  of  the  teeth, 
taking  occasion  to  express  a  doubt  that  such  operation  of  the 
economy  ever  manifested  itself  in  the  absence  of  all  local  disease. 

It  is  always  accompanied  by  a  slight  increase  of  redness, 
tumefaction  and  a  shrinking  of  the  edges  of  the  gums(ulatrophia) ; 
but  the  diseased  action  here  is  so  inconsiderable  as  to  attract 
little  attention.  It  is  also  attended  by  a  slight  discharge  of  puru- 
lent matter  from  between  the  margin  of  the  gum  and  the  tooth, 
but  the  quantity  is  so  small  that  it  usually  escapes  observation. 
The  alveolo-dental  periosteum  participates  also  in  the  diseased 
action,  but  this  is  so  slightly  affected  that  the  tooth  often  remains 
quite  firmly  articulated,  after  the  wasting  of  its  socket  has  pro- 
ceeded even  so  far  as  to  expose  more  than  half  of  the  root.  In- 
deed the  aff"ection  is  so  closely  allied  to  chronic  inflammation  and 
tumefaction  of  the  gums,  as  scarcely  to  require  separate  con- 
sideration. 

The  progress  of  the  disease  is  usually  so  slow  that  ten,  fifteen, 
or  twenty  years  are  required  to  affect  very  perceptibly  the  sta- 
bility of  the  teeth  in  their  sockets.  The  commencement  of  this 
destructive  process  is  usually  first  observed  around  the  cuspid 
teeth ;  sometimes  it  makes  its  first  appearance  on  the  alveoli  of 
the  palatine  roots  of  the  first  and  second  upper  molars,  and 
occasionally  it  goes  on  here  for  years  before  it  affects  the  sockets 
of  any  of  the  other  teeth. 

The  teeth  after  their  roots  have  been  partially  exposed, 
become,    as   might   naturally  be   sup-  yig.  i66. 

posed,  more  susceptible  to  impression 
from  heat  and  cold  and  more  easily 
.affected  by  acids,  or  saccharine  mat- 
ters ;  but  this  is  about  the  only 
manifest  inconvenience  experienced 
from  the  disease,  until  the  teeth  begin 
to  loosen  in  their  sockets. 

In  Fig.  166  is  represented  a  case  in  which  the  roots  of  the 


494  CAUSES    OF   DESTRUCTION    OF   THE    ALVEOLI. 

teeth  have  become  considerably  exposed  by  the  gradual  wast- 
ing of  their  sockets  :  the  destruction  being,  as  is  usual,  greatest 
toward  the  median  line. 

CAUSES. 

The  cause  of  this  peculiar  affection  has  never  been  very  satis- 
factorily explained.  Some  have  supposed  that,  inasmuch  as  it 
occurs  most  frequently  in  persons  of  advanced  age,  it  results 
from  a  decline  of  the  vital  powers  of  the  body,  independently  of 
local  causes.  But,  as  it  is  often  met  with  in  middle-aged  per- 
sons whose  constitutional  health  is  unimpaired,  we  doubt  the 
correctness  of  the  opinion.  In  all  cases  which  have  come  under 
our  observation,  whether  in  middle-aged  or  very  old  persons,  the 
teeth  indicated  an  excellent  innate  constitution,  whatever  may 
have  been  the  state  of  the  general  health  at  the  time.  In  every 
instance  these  organs  were  possessed  of  great  density,  and  this 
fact  is  particularly  noticed  by  Mr.  Fox,  who  says  : 

"  In  a  majority  of  cases  in  which  this  disease  occurs,  the  teeth 
are  perfectly  sound,  and  from  numerous  observations,  we  think 
we  may  venture  to  assert,  that  persons  who  have  had  several  of 
their  teeth  nffected  with  caries  in  the  earlier  part  of  life,  are  not 
liable  to  lose,  by  an  absorption  of  their  sockets,  those  which  re- 
main sound ;  but,  where  the  teeth  have  not  been  affected  with 
caries  in  the  early  part  of  life,  persons,  as  they  approach  the 
age  of  fifty,  and  often  much  earlier,  have  their  teeth  becoming 
loose  from  absorption,  or  a  wasting  of  the  alveolar  process." 

Now  it  is  evident  that  teeth  endowed  with  the  power  of  resist- 
ing to  so  late  a  period  of  life  the  action  of  the  causes  of  decay, 
to  which  all  teeth  are  more  or  less  exposed,  must  be  possessed  of 
extreme  density,  and,  necessarily,  a  correspondingly  low  degree 
of  vitality.  In  view  of  this  fact,  we  have  been  led  to  the  opinion 
that  the  teeth  themselves  may  act,  to  some  extent,  as  mechanical 
irritants  to  the  more  highly  vitalized  parts  with  which  they  are 
immediately  connected,  causing  an  increase  of  vascular  action  in 
the  periosteum  of  the  thin  edges  of  the  alveoli  and  margin  of 
the  gums.  This  abnormal  condition  is  attended  by  a  slight  se- 
cretion of  purulent  matter  observed  between  the  edges  of  the 
gums  and  teeth.  It  is  to  the  corrosive  action  of  this  purulent 
matter  that  the  gradual  destruction  of  the  alveoli  has  by  some 


TREATMEiSTT    OF   DESTRUCTION    OF   THE   ALVEOLI.  495 

been  attributed ;  but  it  is  more  probably  a  result  of  the  obscure 
disease  than  its  cause. 

We  were  for  a  long  time  inclined  to  ascribe  the  increase  of 
vascular  action  in  the  edges  of  the  gums  and  alveolo-dental  peri- 
osteum to  irritation  produced  by  the  pressure  of  the  teeth 
against  the  alveolar  septa;  but  having  met  with  many  cases 
where  the  teeth  were  not  crowded,  we  were  induced  to  enter 
into  a  more  thorough  examination  of  the  possible  causes,  and 
the  foregoing  is  the  only  conclusion  to  which  we  have  been  able 
to  arrive. 

TREATMENT. 

From  what  has  been  said  concerning  the  cause  of  this  affec- 
tion, it  is  obvious  that  a  cure  cannot  be  eflfected.  The  secretion 
of  the  purulent  matter,  to  the  action  of  which  some  attribute  the 
destruction  of  the  alveoli,  is  the  result  of  a  disease  in  the  alveolo- 
dental  periosteum  and  edges  of  the  gums,  arising  from  some 
peculiar  physical  condition  of  the  teeth ;  the  most  we  can  hope 
to  accomplish  is  to  retard  its  progress.  This  can  only  be  done 
by  cleaning  the  teeth  frequently  and  thoroughly,  using  the  pre- 
caution each  time  to  remove  the  purulent  matter  from  between 
the  edges  of  the  gums  and  teeth,  lest,  if  allowed  to  remain,  it 
should  become  putrescent,  and  in  this  condition  act  as  an  irritant 
to  the  gum.  For  this  purpose  a  brush  with  elastic  bristles 
should  be  used,  and  much  benefit  will  be  derived  by  passing  floss 
silk  several  times  a  day  up  and  down  between  the  teeth. 


CHAPTER    SEVENTH. 

DISPLACEMENT   OF   THE   TEETH   BY  A  DEPOSIT   OF 
OSSEOUS  MATTER  IN  THEIR  SOCKETS. 

A  TOOTH  is  sometimes  slowly  forced  from  its  place  by  a  deposit 
of  bony  matter  in  the  bottom  or  on  the  side  of  the  socket.  Two, 
or  even  three  teeth,  may  be  gradually  displaced,  at  the  same 
time,  by  exostosis  of  the  alveoli.  The  deposition  usually  pro- 
ceeds so  slowly  that  one  or  two  years  are  required  to  effect  a 
very  perceptible  change  in  the  situation  of  a  tooth.  The  upper 
central  incisors  are  more  frequently  affected  than  any  of  the 
other  teeth,  and  the  deposit  occurs  oftener  at  the  bottom  than 
on  the  sides  of  the  alveoli.  In  the  first  case,  the  tooth  is 
gradually  protruded  from  the  socket;  in  the  other,  it  is  either 
pressed  out  of  the  arch,  or  against  one  of  the  adjoining  teeth. 
Irregularity  in  the  arrangement  of  the  teeth  is,  in  this  manner, 
sometimes  produced,  especially  when  more  than  one  socket  is 
affected  at  the  same  time.  The  central  incisors  are  sometimes 
forced  apart;  at  other  times  they  are  forced  against  each  other, 
and  caused  to  overlap.  The  deposition  of  bone,  however,  being 
generally  confined  to  the  bottom  of  the  sockets,  the  teeth  are 
more  frequently  thrust  from  their  alveolar  cavities.  When  this 
occurs  with  a  person  whose  upper  and  lower  teeth  strike  directly 
upon  each  other,  it  occasions  much  inconvenience ;  for  the 
elongated  tooth  must  either  be  thrown  from  the  circle  of  the 
other  teeth,  or,  by  striking  its  antagonist,  prevent  the  jaws  from 
coming  together. 

CAUSES. 

So  little  is  known  concerning  the  cause  of  exostosis  of  the 
sockets  of  the  teeth,  that  it  may  seem  almost  useless  to  attempt 
an  explanation  of  it.  That  it  results  from  some  irritation  of  the 
lining  membrane  is  very  generally  believed,  but  what  causes  the 
irritation  does  not  seem  to  be  well  understood.    We  have  thought 


TREATMENT    OF    DISPLACEMENT    OF    THE    TEETH.  497 

that  it  might  sometimes  be  produced  by  pressure  on  the  bottom 
of  the  alveolus,  especially  when  the  extremity  is  nearly  as  large 
as  any  other  part  of  the  root  of  the  tooth.  The  susceptibility 
of  the  lining  membrane  to  morbid  impressions  may  sometimes 
be  so  great  that  the  pressure  of  a  very  conical  root  may  be  suflB- 
cient  to  produce  this  effect;  or,  it  may  be  produced  by  the 
pressure  of  a  tooth  which  possesses  only  a  very  low  degree  of 
vitality.  But  in  connection  with  this  class  of  cases  must  be 
taken  another,  in  which  absence  of  all  pressure  would  seem  to 
be  an  inciting  cause  of  alveolar  exostosis;  as  where  a  tooth  has 
lost  its  antagonist  tooth  or  teeth,  and  in  consequence  becomes 
elongated.  A  diseased  state  of  the  gums  can  have  no  agency  in 
the  production  of  the  exostosis,  for  it  most  frequently  occurs  in 
individuals  whose  gums  are  perfectly  healthy;  and  if  it  were  the 
result  of  any  consitutional  tendency,  all  the  teeth  would  be  as 
likely  to  be  affected  by  it,  as  those  we  have  mentioned. 


TREATMENT. 

When  the  exostosis  is  on  the  side  of  the  alveolar  cavity,  the 
tooth  cannot  be  restored  to  its  natural  position;  but  when  it  is 
in  the  bottom  of  the  socket,  the  elongated  organ  may  from  time 
to  time,  as  it  is  forced  from  the  alveolus,  be  filed  off  even  with 
the  other  teeth ;  but  in  doing  this  care  should  be  taken  to  avoid 
as  much  as  possible  the  unpleasant  jar  which  the  file  is  so  apt 
to  cause,  and  which  might,  in  such  cases,  excite  the  periosteum 
to  increased  activity  and  a  more  rapid  deposit.  This  will  remove 
the  deformity  and  prevent  its  displacement  by  the  antagonizing 
tooth.  By  this  simple  operation,  repeated  as  occasion  may  re- 
quire, it  may  be  preserved  for  years,  and  rendered  almost  as 
useful  as  any  of  the  other  teeth. 


PART    FIFTH. 


DISEASES  OF  THE  MAXILLARY  SINUS,  AND  THEIR 
TREATMENT; 


I 


PART   FIFTH. 


CHAPTER    FIRST. 
PRELIMINARY   REMARKS. 

It  was  not  until  the  knowledge  of  anatomy  had  made  con- 
siderable progress  that  the  existence  of  this  cavity  was  known. 
Casserius,  an  anatomist  of  Padua,  is  supposed  to  have  been  the 
first  to  discover  it.  He  flourished  during  the  latter  part  of  the 
-sixteenth  and  early  part  of  the  seventeenth  centuries;  but  no 
correct  description  of  it  was  given  until  about  the  middle  of  the 
latter ;  the  credit  therefore  of  this  discovery  is  given  to  Nath- 
aniel HiQHMORE,  author  of  a  treatise  on  anatomy,  published  in 
1651.     Hence  its  name,  '"'■  antrum  Ifighmorianum." 

This  cavity  is  subject  to  some  of  the  most  formidable  and  dan- 
gerous diseases  the  medical  or  surgical  practitioner  is  ever  called 
upon  to  treat ;  and  yet  there  are  few  diseases  incident  to  the 
human  body,  that  have  received  less  attention  from  writers  on 
pathology  and  therapeutics  than  these.  There  are  diseases  here 
met  with,  over  which  neither  the  surgeon  nor  physician  can  ex- 
ercise any  control,  the  progress  of  which  ceases  only  with  the 
life  of  the  unfortunate  sufferer. 

All  of  the  diseases  to  which  the  maxillary  antrum  is  subject, 
however,  are  not  of  so  dangerous  a  character,  for  some  are  very 
simple  and  easily  cured ;  but  even  those  which  are  regarded  as 
the  least  dangerous,  and  .which  yield  most  readily  to  treatment, 
when  instituted  during  their  incipient  or  earlier  stages,  may  as- 
sume, if  neglected,  or  improperly  treated,  a  form  so  aggravated 
as  to  bid  defiance  to  the  skill  both  of  the  physician  and  surgeon. 
While  thus,  on  the  one  hand,  the  most  simple  aflfections  of  this 
cavity,  may,  by  neglect  or  improper  treatment,  become  ultimately 


502  PRELIMINARY   REMARKS. 

incurable  ;  many  of  those  on  the  other  hand,  which  are  considered 
the  most  malignant  and  dangerous  might,  we  have  no  doubt,  by 
timely  and  judicious  treatment,  be  effectually  and  radically  re- 
moved. • 

The  form  which  the  disease  puts  on,  is  determined  by  the  state 
of  the  constitutional  health  or  some  specific  tendency  of  the  gen- 
eral system ;  and  we  can  readily  imagine,  that  a  cause  which,  in 
one  person,  would  give  rise  to  simple  inflammation  of  the  lining 
membrane,  or  mucous  engorgement  of  the  sinus,  would,  in  an- 
other, produce  an  ill-conditioned  ulcer,  fungus  hsematodes,  or 
osteo-sarcoma.  Simple  inflammation  and  mucous  engorgement 
not  unfrequently  cause  caries  and  exfoliation  of  the  surrounding 
osseous  tissues,  and,  in  some  instances,  even  the  destruction  of 
the  life  of  the  patient. 

The  importance  of  early  attention  to  the  diseases  of  this 
cavity  is,  therefore,  very  apparent ;  and  this  is  the  more  neces- 
sary, as  it  is  often  difiicult,  and  sometimes  impossible,  to  deter- 
mine the  character  of  the  malady,  until  it  has  progressed  so  far 
as  to  involve,  to  a  greater  or  less  extent,  the  neighboring  parts  ; 
when,  if  it  has  not  become  incurable,  its  removal  is,  to  say  the 
least,  rendered  less  easy  of  accomplishment.  It  may  be  safely 
assumed,  therefore,  that  in  a  very  large  majority  of  the  cases  of 
disease  of  the  maxillary  sinus,  the  danger  to  be  apprehended  arises 
more  from  neglect  than  from  any  necessarily  fatal  character  of 
the  malady,  so  that,  in  forming  a  prognosis,  the  circumstances  to 
be  considered  are,  the  state  of  the  constitutional  health,  the  pro- 
gress made  by  the  affection,  and  the  nature  of  the  injury  inflicted 
by  it  upon  the  surrounding  tissues.  If  the  general  health  is  not 
so  much  impaired  as  to  prevent  its  restoration  by  the  employ- 
ment of  proper  remedies,  and  the  neighboring  structures  have 
not  become  implicated,  the  prognosis  will  be  favorable  ;  but  if 
the  functional  operations  of  the  body  have  become  very  much 
deranged,  and  the  bones  of  the  face  and  nose  seriously  affected, 
the  combined  resources  both  of  medicine  and  surgery  will  prove 
unavailing. 

In  young  and  middle  aged  subjects  of  good  constitution,  a 
morbid  action  may  exist  in  the  antrum  for  years,  without  giving 
rise  to  any  alarming  symptoms,  while  the  same  affection  in 
another  less  healthy,  might  rapidly  extend  and  degenerate  into 


PRELIMINARY    REMARKS.  503 

a  form  of  disease  so  malignant  as  to  threaten  the  speedy  de- 
struction of  the  life  of  the  patient.  Medical  history  abounds 
with  examples  of  this  kind,  and  conclusively  establishes  the  fact 
that  the  state  of  the  general  health  and  habit  of  body,  whatever 
may  have  been  the  primitive  characteristics  of  the  malady,  ulti- 
mately determines  its  malignancy;  in  the  treatment  of  aifections 
of  this  cavity,  therefore,  as  well  as  of  other  local  diseases  of  the 
body,  the  condition  of  the  system  should  not  be  overlooked. 

Independently  of  the  danger  arising  from  the  local  affection, 
diseases  of  the  antrum  are,  for  the  most  part,  very  loathsome, 
and  subject  the  patient  to  great  annoyance.  They  change  the 
qualit}^  of  its  secretions,  and  cause  them  to  exhale  a  fetid,  nau- 
seating odor.  This,  in  many  instances,  is  almost  insufferable  to 
the  patient ;  and  when  they  are  prevented  from  escaping  through 
the  natural  opening  into  the  nose,  they  pass  through  one  arti- 
ficially formed  by  the  surgeon,  or  made  by  the  disease  through 
the  cheek,  alveolar  border,  or  palatine  arch,  always  causing  the 
patient  great  inconvenience. 

The  progress  of  disease  in  this  cavity  is  often  very  insidious. 
It  not  unfrequently  happens  that  it  exists  for  weeks  and  even 
months  before  its  existence  is  suspected.  The  slight  uneasiness 
felt  is  attributed  to  some  morbid  condition  of  the  teeth  or  gums, 
and  the  symptoms  attendant  upon  one  description  of  affection 
are  often  so  similar  to  those  that  accompany  another,  that  it  is 
impossible  to  determine  its  true  character  until  it  has  made  con- 
siderable progress. 

The  morbid  affections  of  the  maxillary  sinus  are,  for  the  most 
part,  similar  to  those  of  the  nasal  fossae.  There  is,  however, 
one  form  of  disease  Avhich  seems  to  be  peculiar  to  this  cavity, 
viz.,  mucous  engorgement.  Deschamps  mentions  two  kinds  of 
accumulations,  dropsical  and  purulent  ;*  but  the  first  of  these  is, 
properly  speaking,  a  disease  of  serous  membranes,  and  is  never 
met  with  in  this  cavity ;  and  authors  who  have  enumerated  it 
among  its  diseases,  have  evidently  mistaken  mucous  engorge- 
ment for  it.  The  fluids  that  accumulate  here  are  of  a  mucous  or 
muco-purulent  character,  except  when  they  are  the  result  of  the 
disorganization  of  some  of  the  surrounding  parts  ;  then  they  are 
sanious. 

*  Traite  des  Maladies  des  Fosses  Nasules  et  les  leurs  Sinus  j  p.  226. 


504  PBELIMINARY    REMARKS. 

The  most  simple  form  of  disease  that  occurs  here,  is  inflamma- 
tion of  the  lining  membrane,  and  this  in  most  instances  may  be 
said  to  precede  all  others.  It  often  subsides  spontaneously,  but 
when  it  continues  for  a  long  time,  is  apt  to  become  chronic,  and 
may  then  give  rise  to  other  and  more  formidable  kinds  of  dis- 
ease. When  unattended  by  any  other  morbid  affection,  either 
local  or  constitutional,  it  is  easily  cured. 

A  purulent  condition  of  the  fluids  of  the  antrum  is  a  common 
affection,  but  is  seldom  met  with  in  persons  of  good  constitution. 
It  seems  to  be  dependent  upon  a  bad  habit  of  body ;  also  upon 
inflammation  of  the  mucous  membrane  of  the  sinus,  which  arises 
more  frequently  from  dental  irritation  than  any  other  cause. 
This  condition  of  the  secretions  sometimes  gives  rise  to  caries 
and  exfoliation  of  portions  of  the  surrounding  bone,  and  to 
fistulous  ulcers ;  but  when  dependent  upon  no  other  local  cause 
than  simple  inflammation  of  the  mucous  membrane,  it  is  seldom 
that  such  efiects  result  from  it.  When  complicated  with  other 
morbid  conditions  of  the  cavity,  they  are  not  unfrequent. 

All  purulent  secretions  of  this  membrane,  are  by  some  denomi- 
nated abscess.  The  name,  however,  as  is  justly  remarked  by 
Mr.  Thomas  Bell,  is  improper.  The  term  abscess  is  more  cor- 
rectly applied  to  purulent  collections  in  the  areolar  tissue — 
either  sub-mucous,  sub-serous,  sub-cutaneous,  inter-muscular  or 
parenchymatous.  It  seldom  originates  in  the  sub-mucous  tissue 
of  the  antrum,  but  proceeds  occasionally  from  disease  in  the 
cancellated  structure  of  the  surrounding  bones.  Instances  of  it 
have  been  met  with  at  the  extremities  of  the  roots  of  teeth  which 
had  perforated  the  sinus ;  and  it  sometimes  happens  that  when 
an  abscess  is  seated  in  the  alveolus  of  a  superior  molar,  the  mat- 
ter, instead  of  making  for  itself  a  passage  through  the  socket  of 
the  tooth  on  cither  side,  escapes  into  this  cavity,  and  thence 
with  the  antral  secretions,  through  the  nasal  opening.  Mr.  Bell 
describes  a  case  of  abscess  seated  in  the  upper  part  of  the  an- 
trum ;  but  this,  and  one  other,  are  the  only  examples  of  the 
kind  on  record. 

Ulceration  of  the  lining  membrane  is  an  aficction  less  fre- 
quently met  with.  It  is  rarely,  if  ever,  idiopathic,  but  seems 
rather  to  be  dependent  upon  some  other  local  malady  or  some 
specific  constitutional  vice.     Scorbutic  and  scrofulous  diatheses. 


PRELIMINARY   REMARKS.  505 

and  those  affected  with  a  venereal  taint,  are  more  liable  to  ulcer- 
ation of  this  membrane  than  persons  of  sound  constitution.  Con- 
sequently, it  is  seldom  cured  by  local  remedies  alone.  It  is 
almost  always  complicated  with  fungus  of  the  membrane  and 
caries  of  the  walls  of  the  sinus,  and  may  if  neglected  take  on  a 
cancerous  form  and  become  incurable. 

The  next  form  of  disease  is  caries  of  the  antral  parietes.  This, 
though  always  complicated  with  other  forms  of  diseased  action, 
seems,  nevertheless,  to  be  worthy  of  separate  consideration. 
Like  ulceration  of  the  lining  membrane,  it  is  the  result  of  some 
other  affection.  It  may  result  from  accumulation  of  the  secre- 
tions of  the  sinus,  from  ulceration,  or  from  tumors. 

The  occurrence  of  fungus  and  of  various  kinds  of  tumor  is 
less  frequent  than  any  of  the  preceding  affections  ;  yet  this 
cavity  is  not  exempt  from  them,  and  they  constitute  the  most 
dangerous  form  of  disease  to  which  the  superior  maxilla  is  sub- 
ject. Although  it  is  probable,  that  in  their  incipient  stage,  they 
might  in  nearly  every  instance  be  radically  removed,  it  is  seldom 
they  are  cured  after  they  have  attained  a  very  large  size,  and 
have  implicated,  to  considerable  extent,  the  surrounding  tissues. 
They  have,  however,  been  successfully  extirpated  even  after 
they  had  acquired  great  volume,  and  implicated  to  such  an  ex- 
tent the  surrounding  parts,  as  to  render  necessary  the  removal 
of  the  whole  of  the  superior  maxillary  bone.  They  usually  grow 
with  great  rapidity,  and  if  not  completely  removed,  are  soon  re- 
produced. 

Besides  these,  other  varieties  of  disease  are  occasionally  met 
with  here.  The  antrum  is  liable  to  injuries,  from  blows  and 
other  kinds  of  mechanical  violence,  and  from  the  introduction  of 
insects  and  foreign  bodies ;  but  of  these,  it  is  not  necessary  to 
speak  in  this  place,  as  they  will  hereafter  come  up  for  special 
consideration.  The  diseases  of  the  maxillary  sinus  are  supposed 
to  be  dependent  upon  certain  specific  constitutional  vices ;  upon 
the  obliteration  of  the  oj5ening  of  this  cavity  into  the  nose  ;  and 
upon  dental  irritation.  That  all  of  these  may,  at  times,  be  con- 
cerned in  their  production,  is  more  than  probable.  But  actual 
disease  rarely  developes  itself  spontaneously  as  a  consequence 
merely  of  a  bad  habit  of  body  or  constitutional  vice.  This  does 
not  of  itself  originate  disease,  but  only  occasions  an  increase  of 
33 


50G  PRELIMINARY    REMARKS. 

susceptibility  of  the  tissues  to  morbid  impressions ;  so  that  when 
an  unhealthy  action  is  once  induced  here,  a  more  aggravated,  or 
a  different  form  of  disease  occurs  than  that  -vvhich  would  other- 
wise have  been  produced. 

Thus  it  n)ay  be  seen,  that  disease  of  the  maxillary  sinus  is 
dependent  upon  some  exciting  cause,  favored  by  some  constitu- 
tional vice  ;  for  without  this,  no  serious  morbid  effects  would  be 
produced,  or  if  produced,  they  would  be  of  a  different  and  less 
aggravated  character.  Any  disposition  or  vice  of  body,  which 
weakens  the  vital  energies  of  the  system,  increases  the  suscepti- 
bility, or  rather  excitability  of  all  its  parts — those  of  this  cavity 
equally  with  the  rest.  There  are  various  kinds  Avhich  have 
this  effect :  as,  for  example,  the  scorbutic,  scrofulous,  venereal, 
mercurial,  etc.,  each  of  which  may  influence  the  character  of  the 
morbid  action  in  a  mannner  peculiar  to  itself;  or  it  may  be  similar 
to  that  which  might  be  exercised  by  another,  only  causing  it  to 
assume  a  greater  or  less  degree  of  malignancy,  accordingly  as  the 
functional  operations  of  the  body  generally  are  more  or  less 
enervated  by  it. 

This  seems  to  be  the  way  in  which  a  bad  habit  of  body  is  ca- 
pable of  affecting  the  maxillary  sinus.  It  is  a  predisposing,  but 
not  an  exciting  cause  of  disease;  and  it  is  important  that  this 
distinction  should  be  borne  in  mind.  The  one  should  never  be 
confounded  with  the  other,  because  an  error  of  this  sort  might, 
in  many  instances,  lead  to  the  adoption  of  incorrect  views  con- 
cerning the  therapeutical  indications  of  the  disease.  This  part 
of  the  subject  we  shall  have  occasion  to  advert  to  hereafter. 

Inflammation  and  ulceration  of  the  nasal  pituitary  membrane 
sometimes  extend  themselves  to  the  maxillary  sinus;  but  disease 
is  not  so  frequently  propagated  from  the  nasal  fossae  to  this  cavity  as 
the  intimate  relationship  between  the  two  might  lead  one  to  suppose. 
It  is  seldom  that  both  are  affected  at  the  same  time.  Hence 
we  infer,  that,  although  lined  by  one  common  membrane,  the 
propagation  of  disease  from  one  to  the  other  is  a  rare  occurrence. 

The  obliteration  of  the  nasal  opening  of  this  cavity  is  some- 
times caused  by  disease  in  the  nose,  and  is  followed  by  mucous 
engorgement  of  the  sinus,  inflammation  of  the  lining  membrane, 
distension  of  the  osseous  walls,  and  not  unfrequently  by  other 
and  more  complicated  forms  of  disease.  But  the  closing  of  this 
opening  is  oftener  an  effect  than  a  cause  of  disease  in  this  cav- 


PRELIMINARY   REMARKS.  507 

ity,  and  it  generally  re-establishes  itself  without  any  assistance 
of  art,  after  the  cure  of  the  affection  which  caused  it. 

If  all  the  circumstances  connected  with  the  history  of  the 
diseases  under  consideration  could  be  ascertained,  we  think  it 
would  be  found  that  these  affections  are  more  frequently  induced 
by  a  morbid  condition  of  the  teeth,  gums  and  alveolar  processes, 
than  any  other  cause.  There  are,  in  fact,  no  sources  of  irrita- 
tion to  which  this  cavity  is  so  much  and  so  often  exposed  as 
those  arising  from  the  dental  organism.  It  is  separated  from 
the  apices  of  the  roots  of  the  superior  molars  and  bicuspids  by 
only  a  very  thin  plate  of  bone,  and-  is  sometimes  even  penetrated 
by  them ;  so  that  it  could  scarcely  be  otherwise  than  that  aggra- 
vated and  protracted  disease  in  the  teeth  and  alveoli  should  ex- 
ert an  unhealthy  influence  upon  it.  The  pain  occasioned  by 
diseased  teeth  is  often  very  severe,  sometimes  almost  excruci- 
ating, and  inflammation  in  the  alveolo-dental  periosteum  and 
gums  frequently  extends  itself  to  the  whole  of  one  side  of  the 
face.  It  could  hardly  be  possible,  therefore,  for  this  cavity  to 
escape.  Alveolar  abscess,  and  sometimes  necrosis  and  exfolia- 
tion of  the  socket  of  the  affected  tooth,  arise  from  the  inflamma- 
tion thus  lighted  up.  It  often  happens  that  the  gums  and  alve- 
olar periosteum  are  affected  for  years  with  chronic  inflammation 
and  other  morbid  affections. 

If,  in  addition  to  these  facts,  other  proofs  be  necessary  to  es- 
tablish the  agency  of  dental  and  alveolar  irritation  in  the  pro- 
duction of  disease  in  the  maxillary  sinus,  they  may  be  found. 
Many  of  the  affections  here  met  with  are  often  cured  by  the 
removal  of  diseased  teeth  after  other  remedies  have  been  em- 
ployed in  vain,  and  that  without  even  perforating  the  antrum. 
This  would  not  be  the  case  if  the  irritation  did  not  arise  as  a 
consequence  of  the  dental  malady. 

Most  writers  on  diseases  of  the  sinus  agree  in  ascribing  them 
to  a  morbid  condition  of  the  teeth  and  alveoli.  There  are  some, 
however,  who,  though  they  admit  that  dental  irritation  may, 
perhaps,  occasionally  give  rise  to  them,  seem,  nevertheless,  to 
attribute  their  occurrence,  in  the  majority  of  instances,  to  other 
causes,  such  as  irregular  exposure  to  cold,  blows  upon  the  face, 
and  certain  constitutional  diseases.  We  shall  now  proceed  to 
the  consideration  of  the  different  affections  of  this  cavity,  under 
their  respective  and  appropriate  heads. 


CHAPTER   SECOND. 

INFLAMMATION   OF   THE   LINING    MEMBRANE   OF  THE 
MAXILLARY  SINUS. 

Inflammation,  when  not  complicated  with  any  other  morbid 
affection,  is  the  most  simple  form  of  disease  to  which  the  pitui- 
tary membrane  of  the  antrum  is  subject.  As  it  precedes  and 
accompanies  all  others,  it  will  be  proper  to  offer  a  few  remarks 
upon  it,  before  entering  upon  the  consideration  of  those  of  a  more 
aesravated  nature. 

Inaccessible  as  it  is  here  to  most  of  the  acrid  and  irritating 
agents  to  which  it  is  exposed  in  the  nasal  fossae  and  some  other 
cavities  of  the  body,  it  would  rarely  become  the  seat  of  inflamma- 
tion, were  it  not  for  its  proximity  to  the  teeth  and  alveolar  bor- 
der ;  and  simple  inflammation  rarely  gives  rise  to  any  other  form 
of  diseased  action,  unless  favored  by  some  general  morbid  tend- 
ency, but  usually  subsides  spontaneously  on  the  removal  of  the 
exciting  cause.  In  good  constitutions,  it  is  less  subject  to  in- 
flammation, and  consequently,  to  any  other  description  of  morbid 
action,  than  those  in  whom  there  exists  some  vice  of  body,  or 
constitutional  predisposition.  Febrile  and  gastric  affections ; 
eruptive  diseases,  such  as  measles,  small  pox,  etc. ;  syphilis,  and 
excessive  and  protracted  use  of  mercurial  medicines  ;  a  scorbutic 
or  scrofulous  diathesis  of  the  general  system  ;  in  short,  every- 
thing that  has  a  tendency  to  enervate  the  vital  powers  of  the 
body,  increases  its  irritability. 

When  in  a  healthy  condition,  it  secretes  a  slightly  viscid,  trans- 
parent and  inodorous  fluid,  by  which  it  is  constantly  lubricated, 
but  inflammation  changes  the  character  of  the  secretion  ;  it  causes 
it  to  become  vitiated ;  at  first  less  abundant,  it  is  afterwards  se- 
creted in  larger  quantities  than  usual,  becomes  more  serous,  and  so 
acrid  as  sometimes  to  irritate  the  membrane  of  the  nose,  over 
which  it  passes  after  having  escaped  from  the  antrum.  It  also 
exhales  an  odor  more  or  less  offensive,  accordingly  as  the  inflam- 


SYMPTOMS    OF    INFLAMMATION,  509 

mation  is  mild  or  severe.  It  moreover  gives  rise  to  a  thickening 
of  the  membrane,  and  sometimes  to  obliteration  of  the  nasal 
opening.  This  last  rarely  occurs,  but  when  it  does  happen,  an 
accumulation  of  the  secretion  and  other  morbid  phenomena  of 
which  wo  shall  hereafter  treat,  result  as  a  necessary  consequence. 

If  at  any  time  during  the  continuance  of  the  inflammation, 
the  patient  is  attacked  with  severe  constitutional  disease,  the 
local  affection  will  be  aggravated,  and  sometimes  assume  a  difier- 
ent  character. 

The  inflammation,  when  long  continued,  degenerates  into  a 
chronic  form,  and  is  sometimes  kept  up  for  several  years,  with- 
out giving  rise  to  any  other  unpleasant  symptoms  than  occasional 
paroxysms  of  dull  and  seemingly  deep-seated  pain  in  the  face, 
and  a  vitiated  condition  of  the  fluids  of  this  cavity.  The  slightly 
fetid  odor  which  they  exhale,  ceases  to  be  annoying  or  even  per- 
ceptible to  the  patient,  when  he  becomes  accustomed  to  it. 

SYMPTOMS. 

The  symptoms  of  inflammation  here,  though  not  always  pre- 
cisely the  same  as  elsewhere,  are,  for  the  most  part,  very 
similar.  They  are  severe,  fixed,  and  deep-seated  pain  under  the 
cheek,  extending  from  the  alveolar  border  to  the  lower  part  of 
the  orbit;  local  heat,  pulsation  and  sometimes  fever.  Beyer 
Bays  these  symptoms  are  not  always  present,  and  that  inflamma- 
tion may  exist  when  it  is  not  suspected.  Other  affections  of  the 
face  and  superior  maxilla,  may  be  mistaken  for  this,  and  this  for 
others;  but  that  inflammation  should  exist  without  being  at- 
tended with  pain  or  any  other  signs  indicative  of  its  presence,  is 
scarcely  probable. 

Deschamps  distinguishes  the  symptoms  of  this  from  those  of 
other  affections  of  this  cavity,  by  a  dull,  heavy  pain  in  the  region 
of  the  sinus,  which,  he  says,  becomes  sharp  and  lancinating,  and 
extends  from  the  alveolar  arch  to  the  frontal  sinus.  The  disease 
goes  on  without  interruption,  increasing  until  the  superior  max- 
illa of  the  affected  side  is  more  or  less  involved.  This  malady, 
he  says,  cannot  be  confounded  with  any  other,  even  where  there 
is  no  external  visible  cause;  differing  from  a  simple  retention  of 
mucus,  by  being  painful  at  the  commencement,  and  by  not  being 


510  CAUSES    OF   INFLAMMATION. 

accompanied  with  swelling  of  the  bones;  from  polypus,  by  the 
continuance  of  pain  ;  and  from  cancer,  by  the  character  of  the 
pain.  "  Suppuration  and  ulcers  have  peculiar  signs  which  can- 
not be  confounded  with  those  of  inflammation."  Pain  in  the 
molar  and  bicuspid  teeth,  accompanied  by  a  sense  of  fluctuation 
in  the  parts,  he  seems  to  regard  as  a  very  certain  indication  of 
inflammation,  and,  especially,  when  joined  to  the  other  symp- 
toms. "  If  an  external  cause  is  discovered,  it  will  furnish  a 
certain  diagnosis;"  he  also  mentions  fever  and  headache  as 
almost  invariable  accompaniments. 

The  inflammation,  if  not  subdued  by  appropriate  remedies, 
after  having  continued  for  a  length  of  time,  gradually  assumes 
a  chronic  form ;  the  pain  then  begins  to  diminish,  and  is  less 
constant;  it  becomes  duller,  and  is  principally  confined  to  the 
region  of  the  antrum.  The  teeth  of  the  affected  side  cease  to 
ache,  or  ache  only  at  times,  but  still  remain  sensitive  to  the 
touch.  The  mucous  membrane  of  the  nostril  next  the  diseased 
sinus,  is  often  tender  and  slightly  inflamed ;  and  if  in  the  morn- 
ing, or  after  two  or  three  hours'  sleep,  the  other  nostril  be  closed 
by  pressing  upon  it  Avith  the  thumb  or  one  of  the  fingers,  and  a 
violent  expiration  be  made,  a  thin  watery  fluid,  of  a  slightly 
fetid  odor,  will  be  discharged,  and  pain  will  be  experienced  in 
the  region  of  this  cavity. 

CAUSES. 

All  morbid  conditions  of  the  teeth  and  gums,  causing  irritation 
in  the  alveolar  periosteal  tissue,  may  be  regarded  as  among  the 
most  frequent  of  its  exciting  causes,  especially  caries,  necrosis, 
and  exostosis;  also,  loose  teeth,  and  the  roots  of  such  as  have 
been  either  fractured  in  an  attempt  at  extraction,  or  by  a  blow 
or  fall,  and  left  in  their  sockets,  or  that  have  remained  after  the 
destruction  of  their  crowns  by  decay.  It  sometimes  happens, 
too,  that  inflammation  is  excited  in  this  membrane  by  fractured 
alveoli;  but  when  an  accident  of  this  sort  occurs,  the  detached 
portions  of  bone  are  generally  soon  thrown  off"  by  the  economy, 
and  the  cause  being  removed,  the  inflammation  immediately  sub- 
sides. Not  so  with  the  roots  of  the  teeth.  They  often  remain 
concealed  in   their   sockets  for  years,  unless   removed   by  art. 


i 


TREATMENT    OF    INFLAMMATION.  511 

Nature,  it  is  true,  makes  an  effort  to  expel  them  from  the  jaw, 
but  this  is  accomplished  only  by  a  slow  and  very  tedious  process, 
and  not,  in  many  instances,  until  they  have  given  rise  to  some 
serious  affection.  But  of  the  deleterious  effects  that  result  from 
necrosed  roots  of  teeth  in  the  alveoli,  it  is  not  necessary  now  to 
speak;  as  extraneous  bodies,  they  are  always  productive  of  more 
or  less  irritation.  We  might  also  mention  exposure  to  sudden 
transitions  of  temperature,  and  certain  constitutional  diseases, 
as  among  the  causes  which  occasionally  give  rise  to  inflammation 
of  this  membrane. 

TREATMENT. 

The  curative  indications  of  inflammation  of  the  lining  mem- 
brane of  the  antrum  are  simple,  and,  for  the  most  part,  similar 
to  those  of  inflammation  in  other  parts  of  the  body.  Bleeding 
from  the  arm,  saline  purgatives,  and  fomentations  to  the  face, 
and  other  antiphlogistic  measures,  may  be  resorted  to  with 
advantage.  In  many  cases,  great  benefit  will  be  derived  from 
the  application  of  leeches  to  the  cheek,  as  recommended  by  Mr. 
Thomas  Bell.  When  the  disease  is  dependent,  as  in  most  in- 
stances it  is,  upon  an  unhealthy  condition  of  the  alveolar  pro- 
cesses, the  first  thing  to  be  done  is  to  remove  all  such  teeth,  or 
roots  of  teeth,  as  are  productive  of  the  least  irritation;  for  while 
any  local  sources  of  irritation  are  permitted  to  remain,  neither 
topical  nor  general  bleeding,  or  indeed  any  other  treatment,  will 
be  of  permanent  advantage. 

Simple  inflammation  cf  the  lining  membrane  of  the  antrum, 
would  be  of  little  consequence,  were  it  not  that  it  is  liable  to 
give  rise  to  other  and  more  dangerous  forms  of  disease,  such,  for 
instance,  as  engorgement  or  a  purulent  condition  of  its  secretions. 
It  should  never,  therefore,  be  permitted  to  continue,  but  be  as 
speedily  arrested  as  possible  ;  and  for  the  accomplishment  of  this, 
the  means  here  pointed, out,  will,  if  timely  and  properly  applied, 
be  found  fully  adequate. 


CH  APT  E  R     THIRD. 

PURULENT  CONDITION  OF    THE    SECRETIONS    AND   EN- 
GORGEMEJ^T  OF   THE   MAXILLARY  SINUS. 

A  PURULENT  condition  of  the  secretions  of  the  maxillary  sinus 
and  mucous  engorgement  are,  indiscriminately,  though  very  im- 
properly, denominated  by  many  writers  on  the  affections  of  this 
cavity,  abscess.  To  this,  neither  bears  the  slightest  resemblance. 
Deschamps  treats  of  the  former  under  the  name  of  suppuration, 
and  the  latter,  dropsy.  Of  the  first,  he  says,  "  If  by  the  time 
the  inflammation  has  passed,  the  surrounding  parts  cease  to  be 
painful,  -while  the  affection  still  continues  to  cause  pain  in  the 
antrum,  and  the  fever,  though  diminished,  occurs  at  irregular 
intervals,  and  if  the  inflammation  is  followed  by  pulsating  pain, 
■we  have  reason  to  suppose  that  an  abscess  has  formed  in  the 
sinus ;  and  all  doubt  will  be  removed,  if,  on  the  patient's  in- 
clining his  head  to  the  opposite  side,  matter  is  discharged  into 
the  nostrils,  or  if  some  tubercles  are  formed  near  the  outer  angle 
of  the  eye,  or  alveolar  border,  which  last  happens  more  fre- 
quently ;  and,  finally,  if  the  purulent  matter,  not  finding  any 
opening  through  which  to  discharge  itself,  distends  the  sinus  to 
such  an  extent  as  to  form  a  tumor  outwardly  upon  the  cheek." 
In  short,  all  the  symptoms  which  he  mentions  as  belonging  to 
the  disease,  are  those  accompanying  the  one  under  considera- 
tion.    The  matter,  he  says,  is  of  a  "putrid  serous  consistence." 

Bordenave  has  fallen  into  a  similar  error.  He  terms  an  altered 
state  of  these  secretions,  suppuration  of  the  membrane,  and  says 
that  inflammation  is  not  necessary  to  it.  He  seems  to  have  con- 
founded with  abscess  of  the  antrum  those  cases  of  alveolar 
abscess  where  the  matter,  instead  of  discharging  itself,  as  it 
ordinarily  does,  by  an  opening  through  the  alveolus  and  gum 
into  the  mouth,  passes  into  that  cavity.  Again  he  asserts  that 
the  disease  (suppuration  as  he  calls  it)  may  be  independent  of 
the  surrounding  parts ;  and  although  ordinarily  implicated  with 


PURULENT   SECRETIONS    AND    MUCOUS    ENGORGEMENT.      513 

an  altered  condition  of  them,  he  affirms,  it  is  sometimes  the 
effect  of  disease  primarily  seated  in  this  cavity.* 

There  is  no  doubt  that  a  purulent  condition  of  the  fluids  of  this 
cavity  is  often  complicated  with  ulceration  of  the  lining  mem- 
brane, but  that  the  affection  is  different  from  abscess,  its  very 
nature  and  situation  is  sufficient  to  show.  "  A  reference  to  the 
structure  of  the  antrum,"  says  Mr.  Bell,  "would  appear  to  be 
sufficient  to  point  out  the  improbability,  to  say  the  least,  of  the 
occurrence  of  abscess  in  such  a  situation.  That  a  mucous  mem- 
brane covering,  in  a  thin  layer,  the  whole  internal  surface  of 
such  a  cavity,  should  become  the  seat  of  all  the  consecutive 
steps  of  true  abscess,  is  a  statement  bearing  on  the  face  of  it  an 
obvious  absurdity. "f  Notwithstanding  the  seeming  improba- 
bility of  such  an  occurrence,  and  it  is  certainly  one  that  very 
rarely  happens,  abscess  does  sometimes  develop  itself  in  this 
cavity  ;  but,  it  is  a  different  affection  altogether  from  that  usually 
treated  of  under  that  name.  We  have  already  adverted  to  a 
case  narrated  by  Mr.  Bell,  a  description  of  which,  we  intend 
hereafter  to  give. 

When  complicated  with  ulceration  of  the  mucous  membrane — 
and  it  is  probable  that  a  purulent  condition  of  its  secretions,  in 
most  instances,  is  thus  complicated — the  affection  is  analogous 
to  ozena,  and  many  of  the  older  writers  designate  it  by  that 
name.  Mr.  Bell  describes  it,  and  very  properly  too,  as  being 
similar  to  gonorrhoea ;  both  diseases  alike  consist  in  an  alteration 
of  secretion ;  in  the  one  case  of  the  pituitary  membrane,  and  in 
the  other  of  the  mucous  lining  of  the  urethra ;  but  in  neither 
instance  does  it  possess  any  of  the  characteristics  of  abscess, 
though  the  matter  in  both  is  purulent. | 

It  has  been  before  stated  that  the  obliteration  of  the  nasal 
opening  was  more  frequently  an  effect  than  a  cause  of  disease  in 
the  maxillary  sinus ;  it  does,  however,  sometimes  become  closed 
from  other  causes  than  an  unhealthy  condition  of  this  cavity ; 
when  this  happens,  engorgement  of  the  sinus  is  the  inevitable 
consequence.  The  fluids  thus  accumulated  are  not  always  at 
first  purulent,  although  they  may  subsequently  become  so ;  when 
the  closing  of  the  opening  is  the  result  of  previous  disease  in 

■■■■•  Memoires  dc  rAcatleraie  Royalc  Chirurg.,  vol.  12,  p.  8. 

t  Anat.  Physiol,  and  Diseases  of  the  Teeth,  p.  253.  J  Ibid.  p.  254. 


514      PURULENT    SECRETIONS    AND    MUCOUS    ENGORGEMENT. 

the  antrum,  tlie  secretions  are  more  or  less  altered  from  the  very 
first. 

Accumulation  of  any  secretion  within  the  antrum,  whether  of 
mucus  or  pus,  is  a  source  of  irritation  to  the  lining  membrane, 
and  the  pressure  which  it  ultimately  exerts  upon  the  surrounding 
walls,  causes  a  new  form  of  diseased  action,  which  not  unfre- 
quently  involves  in  disease  all  the  bones  of  the  face  as  well  as 
those  of  the  base  of  the  cranium.  When  prevented  from  escap- 
ing through  the  nasal  opening,  the  secretion  eventually  makes 
for  itself  a  way  of  escape — sometimes  through  the  cheek ;  at 
other  times  beneath  it,  just  above  the  alveolar  ridge ;  or  through 
the  palatine  arch  or  alveoli  by  the  sides  of  the  roots  of  one  or 
more  of  the  teeth ;  and  from  a  fistula  thus  established,  fetid 
matter  will  be  almost  constantly  discharged.  From  openings  of 
this  sort  the  matter  is  sometimes  discharged  for  years,  while  the 
disease  in  the  antrum,  very  frequently,  does  not  seem  to  undergo 
any  apparent  change.  At  other  times  the  membrane  ulcerates 
and  the  bony  walls  become  carious. 

A  purulent  secretion  from  the  mucous  membrane  of  this  cavity, 
independently  of  caries  of  the  bone,  or  even  of  simple  fistulous 
openings,  is  an  exceedingly  troublesome  and  unpleasant  afi"ec- 
tion.  The  odor  from  the  matter  is  often  very  annoying  even  to 
the  patient,  and  when  the  secretions  are  retained  for  some  days 
in  the  sinus  before  they  escape,  the  fetor  is  almost  insufierable. 

In  good  constitutions,  the  secretions  of  the  antrum  are  not  so 
liable  to  become  purulent,  though  they  be  confined  for  a  long 
time  in  the  cavity,  and  thus  become  more  or  less  offensive.  In- 
flammation of  the  lining  membrane  (tlie  immediate  or  proximate 
cause)  may  exist  for  years  without  giving  rise  to  it.  It  is  only 
in  scrofulous,  scorbutic,  or  debilitated  habits  that  they  are  liable 
to  become  thus  altered.  The  difference  in  the  eflFects  produced 
upon  them  and  the  surrounding  parts,  by  inflammation,  is  owing 
to  the  difierences  in  the  state  of  the  constitutional  health  of 
those  aff'ected  with  it. 

Where  a  puriform  state  of  the  secretions  is  complicated  with 
ulceration  of  the  membrane,  the  matter  will  have  mixed  with  it 
a  greater  or  less  quantity  of  flocculi,  sometimes  of  so  firm  a 
consistence,  as  to  block  up  the  nasal  opening  and  prevent  its 
exit.     Mr.  Thomas  Bell  says,  he  has  seen  more  than  one  case  in 


PURULENT    SECRETIONS    AND    MUCOUS    ENGORGEMENT.      515 

which  a  considerable  accumulation  had  taken  place  in  the  an- 
trum, accompanied  by  the  usual  indications  of  this  aifection, 
(muco-purulent  engorgement  of  the  sinus,)  when  a  sudden  dis- 
charge of  the  contents  into  the  nose  took  place,  "in  consequence 
of  the  pressure  having  overcome  the  resistance  which  had  thus 
been  offered  to  its  escape."*  Cases  of  a  very  similar  nature  have 
fallen  under  our  observation,  the  history  of  one  of  which  will  be 
given  in  the  course  of  this  chapter.  The  formation  of  these 
flocculi  rarely  ceases,  except  with  the  cure  of  the  ulcers  on  the 
membrane.  They  give  rise  to  considerable  irritation,  and  their 
presence  always  constitutes  an  obstacle  to  the  cure.  They  are 
usually  easily  removed  by  injections. 

The  pituitary  membrane  of  the  antrum,  when  in  a  healthy 
state,  secretes,  as  we  have  before  stated,  a  transparent,  slightly 
viscid  and  inodorous  fluid,  poured  out  only  in  sufficient  quantity 
to  lubricate  the  cavity.  But  when  inflammation  is  excited  in 
the  membrane,  its  secretions  soon  become  more  abundant,  and 
are  at  first  thinner,  afterwards  thicker  and  more  glutinous. 
Their  color  and  consistence  are  not  always  the  same.  Instead 
of  being  transparent,  they  sometimes  have  a  dirty  opaque  ap- 
pearance; at  other  times  they  assume  a  greenish,  whitish  or 
yellowish  color,  and  in  some  instances  they  bear  a  considerable 
resemblance  to  pus,  which,  it  has  been  conjectured,  might  be 
owing  to  suppuration  of  some  of  the  mucous  follicles  and  a  mix- 
ture of  pus  with  its  secretions.  Mr.  Thomas  Bell,  however,  in- 
clines to  the  opinion  that  it  is  attributable  to  an  "  alteration 
simply"  of  the  secretions  of  the  cavity.  Their  color  and  con- 
sistence are  determined  by — the  degree  of  inflammation;  the 
length  of  time  it  has  existed ;  the  state  of  the  health  of  the 
lining  membrane,  and  that  of  the  surrounding  osseous  walls; 
the  egress  which  the  matter  has  from  the  sinus ;  and  the  general 
habit  of  the  body. 

Affections  of  this  sort  are  more  common  to  young  subjects 
than  to  middle-aged  or'  persons  in  advanced  life.  An  eminent 
French  writer  says,  that  of  three  individuals  affected  with  dropsy 
(mucous  engorgement),  the  oldest  was  not  twenty  years  of  age. 

*  Anat.  Physiol,  and  Diseases  of  the  Teeth,  p.  258. 


516  SYMPTOMS    OF    PURULENT    SECRETIONS,    ETC. 


SYMPTOMS. 

The  diagnoses  of  the  several  affections  of  the  antrum  are  so 
much  alike,  that  it  is  often  difficult  to  distinguish  those  that  be- 
long to  one  from  those  attendant  upon  another.  The  symptoms 
of  mucous  engorgement  and  purulent  accumulation,  however,  are 
generally  such  as  Avill  enable  the  practitioner  to  distinguish,  with 
considerable  certainty,  these  from  other  affections.  They  are 
always  preceded  by  inflammation  of  the  lining  membrane;  a  de- 
scription of  the  symptoms  of  which,  having  already  been  given, 
need  not  be  repeated.  Omitting  these,  we  at  once  proceed  to 
mention  those  by  which  they  are  accompanied. 

In  speaking  of  the  symptoms  more  particularly  belonging  to  a 
purulent  condition  of  the  secretions  of  the  antrum,  Deschamps 
says,  the  affection  may  be  distinguished  by  dull  heavy  pain,  ex- 
tending along  the  alveolar  border.  Upon  this  symptom  alone, 
little  reliance  can  be  placed,  as  it  is  always  present  in  chronic 
inflammation.  In  addition  to  this,  he  mentions — the  presence  of 
decayed  teeth ;  soreness  in  those  that  are  sound ;  and,  on  the 
patient's  inclining  his  head  to  the  side  opposite  the  one  affected, 
the  discharge  of  fetid  matter  from  the  nose.  These  are  very 
conclusive  indications  of  purulent  effusions  in  this  cavity.  Bor- 
denave,  after  enumerating  the  symptoms  indicative  of  inflamma- 
tion, mentions  the  following  as  belonging  to  the  affection  of  which 
we  are  now  speaking, — dull  and  constant  pain  in  the  sinus,  ex- 
tending from  the  maxillary  fossae  to  the  orbit ;  a  discharge  of 
fetid  matter  from  the  nose,  when  the  patient  inclines  his  head  to 
the  opposite  side,  or  when  the  nose  is  blown  from  the  nostril  of 
the  affected  side.*  These  symptoms  are  mentioned  by  almost 
every  writer  upon  the  subject,  as  indicative  of  a  purulent  condi- 
tion of  the  secretions  of  the  maxillary  sinus. 

The  symptoms  of  engorgement  differ  materially  from  those 
which  denote  simply  a  purulent  condition  of  the  mucous  secre- 
tions. The  pain,  instead  of  being  dull  and  heavy,  as  just  de- 
scribed, becomes  acute,  and  a  distressing  sense  of  fullness  and 
weight  is  felt  in  the  cheek,  accompanied  by  redness  and  tume- 

*Memoires  de  TAcadeniie  Royale  de  Ohirurgie,  12mo,  torn.  12,  p.  10. 


CAUSES    OF    PURULENT    SECRETIONS,    ETC.  517 

faction  of  the  integument  covering  the  antrum.*  The  nasal 
opening  having  become  closed,  the  fluids  of  the  cavity  gradually 
accumulate  until  they  fill  it ;  when,  finding  no  egress,  they  press 
upon  and  distend  the  surrounding  osseous  walls,  causing  those 
parts  which  are  the  thinnest  ultimately  to  give  way.  The  effects 
are  generally  first  observable  anteriorly  beneath  the  malar  pro- 
minence, where  a  smooth  hard  tumor  presents  itself,  covered 
with  the  mucous  membrane  of  the  mouth.  But  this  is  not  always 
the  point  which  first  gives  away,  the  sinus  sometimes  bursts  into 
the  orbit,  at  other  times  outwardly  through  the  cheek,  or  through 
the  palatine  arch.  The  long  continued  pressure  thus  exerted 
upon  the  bony  walls,  often  causes  the  breaking  down  or  softening 
of  their  tissues. 

The  tumor,  which  is  at  first  hard,  becomes  in  a  short  time  so 
soft  as  readily  to  yield  to  pressure.  A  distension,  Deschamps 
says,  may  be  distinguished  from  other  diseases  that  affect  the 
skin  or  subcutaneous  tissues  by — the  uniformity  or  regularity  of 
the  tumor  ;  its  firmness  at  the  commencement ;  the  slowness  with 
which  it  progresses ;  and,  above  all,  by  the  natural  appearance 
of  the  skin,  and  the  absence  of  pain  when  pressure  is  made  upon 
the  tumor.  Obliteration  of  the  nasal  opening,  he  says,  may  be 
suspected  by  the  dryness  of  the  nostril  of  the  affected  side,  the 
mucous  membrane  of  which  becomes  thickened,  and  the  cavity 
contracted  ;  inflammation  and  sponginess  of  the  gums,  loosening 
and  sometimes,  (in  consequence  of  the  destruction  of  their 
sockets,)  displacement  of  the  teeth,  may  also  be  mentioned  as 
occasional  accompaniments  of  engorgement. 


CAUSES, 

Inflammation  of  the  mucous  membrane  is  the  cause  of  a  puru- 
lent condition  of  the  secretions  of  the  maxillary  sinus,  and  this 
arises  more  frequently  from  alveolo-dental  irritation  than  from 
any  particular  habit  of  body  or  constitutional  disturbance.  En- 
gorgement results  from  the  obliteration  of  the  nasal  opening, 
which,  in  the  case  of  altered  secretion,  is  usually  caused  by  in- 
flammation and  thickening  of  the  lining  membrane. 

*  Bell  on  the  Teeth,  p.  256,  see  also  Maladies  des  Fosses  Nasales,  p.  228. 


518  TREATMENT    OF    PURULENT    SECRETIONS,    ETC. 


TREATMENT. 

The  curative  indications  of  muco-purulent  secretion  and  en- 
gorgement of  the  maxillary  sinus  are,  1st,  if  the  nasal  opening 
be  closed,  the  evacuation  of  the  retained  matter;  2dly,  the  re- 
moval of  all  local  and  exciting  causes  of  irritation ;  3dlj,  and 
lastly,  the  restoration  of  the  lining  membrane  to  its  normal 
function. 

For  the  fulfillment  of  the  first,  an  opening  must  be  made  into 
the  antrum,  and  this  should  be  efi"ected  in  that  part  which  will 
afi"ord  the  most  easy  exit  to  the  retained  matter.  Several  ways 
have  been  proposed  for  the  accomplishment  of  this  object,  and 
before  we  proceed  further,  it  may  not  be  amiss  to  notice  some 
of  the  various  methods  that  have  been  adopted  by  different 
practitioners. 

Dr.  Drake,  an  English  anatomist,  and  author  of  a  work  en- 
titled '■'■  Anthropologia  Nova,"  has  the  credit  of  being  the  first  to 
propose  the  perforation  of  the  floor  of  the  sinus  through  the 
alveolus  of  one  of  the  roots  of  a  molar  tooth.  This  method,  how- 
ever, is  said  by  some  to  have  been  inserted  into  Drake's  Anatomy 
by  Mr.  Cowper,  an  eminent  anatomist  and  surgeon.*  M.  Gunz 
says  the  credit  belongs  to  John  Henry  Meibomius,  who,  a  long 
time  before,  proposed  a  very  similar  method  of  treating  these 
afiections.f  Henry  Meibomius,  many  years  after  the  death  of  his 
father,  John  Henry,  proposed  for  the  evacuation  of  accumulated 
fluids  in  the  antrum,  the  extraction  of  one  of  several  teeth.]:  It 
is  not  all  probable  that  Meibomius  was  the  first  to  propose  the 
perforation  of  the  antrum  in  this  way,  for  his  researches  were 
not  published  until  1718,  twenty-one  years  after  the  publication 
of  Drake's  System  of  Anatomy,  and,  besides,  he  regarded  the 
perforation  of  this  cavity  as  a  dangerous  operation,  and,  on  that 
account,  confined  himself  simply  to  the  extraction  of  a  tooth. 
The  perforation  of  this  cavity  through  the  alveolus  of  a  superior 
molar  is  an   operation  which  was  performed  by  Swinger  a  long 

*  Heister's  Surgery,  note  to  chapter  72,  p.  445. 

.  de  I'Acad.  Royale  de  Chirurg.  12mo,  vol.  xii,  p.  12. 

irs.  de  Abscessibus    Internis.  Dresd.,   1713,  p.    114,  and    La  Dissertation 


TREATMENT    OF    PURULENT    SECRETIONS,    ETC.  519 

time  before  it  was  made  by  Meibomius,  according  to  Velpeau ; 
who  also  says  that  Saint  Yves  treated  with  success  a  person 
affected  with  fistula,  the  floor  of  whose  orbit  had  been  destroyed 
by  the  removal  of  a  tooth  ;  and  Vanuessen  says  Ruysch  extracted 
several  molars  and  cauterized  their  sockets,  for  the  destruction 
of  a  polypus,  until  an  opening  was  made  into  the  antrum  large 
enough  to  admit  the  finger ;  but  we  are  also  informed  by  Borde- 
nave  that  Cowper  treated  a  case  of  maxillary  ozena,  which  had 
caused  a  large  quantity  of  ichorous,  fetid  matter,  to  be  dis- 
charged through  the  nose,  by  extracting  the  first  molar,  and 
perforating  the  antrum  through  the  alveolus  with  an  instrument 
suited  to  the  purpose ;  Drake,  according  to  the  same  author, 
seems  to  be  entitled  to  the  credit  of  having  been  the  first  to  per- 
forate the  maxillary  sinus  as  above  described. 

With  regard  to  the  tooth  most  proper  to  be  extracted  authors 
differ.  Cheselden  preferred  the  first  or  second  molar,  Junker 
recommends  the  extraction  of  the  first  or  second  bicuspid,  and  if 
a  fistula  had  formed,  to  enlarge  it  instead  of  perforating  the 
floor  of  the  antrum.  But  the  second  molar,  being  directly  be- 
neath the  most  dependent  part  of  the  cavity,  is  the  most  suitable 
tooth  to  be  removed.  If  this  be  sound,  the  first  or  third  molar 
or  either  of  the  bicuspids,  if  carious,  may  be  extracted  in  its 
stead,  and  in  fact,  no  tooth  beneath  the  antrum,  in  an  unhealthy 
condition,  should  be  permitted  to  remain. 

An  opening  having  been  effected  through  the  alveolus  of  a 
tooth  into  the  antrum,  it  should  be  kept  open  until  the  health  of 
the  cavity  is  restored.  For  this  purpose,  sounds  and  bougies 
adapted  to  the  purpose  have  been  introduced.  Heuerman  recom- 
mends the  employment  of  a  small  canula,  which  is  also  preferred 
by  Bordenave  and  Ritehtcr,  tlie  latter  of  whom  says,  it  should 
be  kept  closed  to  prevent  particles  of  food  from  getting  into  the 
sinus.  But  whether  a  canula  or  bougie  be  introduced  into  the 
opening,  it  should  be  so  secured  as  to  prevent  it  from  falling  out 
or  passing  into  the  antrum.  Dcschamps  recommends  that  it  be 
fastened  to  one  of  the  adjoining  teeth  by  means  of  a  silk  or 
metallic  ligature. 

But  the  perforation  of  the  maxillary  sinus  through  the  alveo- 
lus of  a  molar  tooth,  is  said  not  to  be  the  most  ancient  method. 
Molinetti,  as  early  as  the  year  1675,  describes  an  opening  made 


520      TREATMENT  OF  PURULENT  SECRETIONS,  ETC. 

through  the  cheek  into  the  antrum,  the  wall  of  which,  after 
having  been  exposed  by  a  crucial  incision  through  the  integu- 
ments covering  it,  was  penetrated  with  a  trephine. 

Lamorier,  an  eminent  surgeon  of  Montpellier,  recommended 
perforating  the  antrum  immediately  above  the  first  molar,  or 
rather  between  it  and  the  malar  bone.  In  this,  he  seems  to  have 
been  influenced  by  the  consideration  that  the  wall  of  the  cavity 
here  presents  the  least  thickness,  and  that  this  is  the  most  de- 
pendent part  of  the  sinus.  If  a  fistulous  opening  had  previously 
formed  in  some  other  place  in  the  mouth,  he  did  not  always  deem 
it  necessary  to  make  another.  His  method  of  operating  is  as 
follows  :  The  jaws  being  closed,  the  commissure  of  the  lips  are 
drawn  outward  and  slightly  upward  with  a  curved  speculum ; 
this  done,  the  gum  is  incised  across  the  malar  apophysis,  or 
maxillo-labial  sulcus,  the  bone  made  bare,  and  then  pierced  with 
a  spear-pointed  punch.  The  opening  may  afterwards  be  en- 
larged if  found  necessary. 

Desault  prefers  that  the  opening  should  be  made  through  the 
canine  fossa,  beneath  the  upper  lip,  and  for  that  purpose,  after 
having  laid  bare  the  bone,  he  employed  a  sharp  triangular  and 
blunt  pointed  perforator,  which  he  invented  for  the  operation. 
Runge,  says  Velpeau,  used  nothing  but  a  scalpel.  Mr.  Charles 
Bell  invented  a  trephine  for  the  purpose,  but  this  does  not 
possess  any  advantage  over  the  instruments  employed  by  Desault 
and  Runge.  In  case  of  fistulai,  in  the  cheek  from  the  antrum, 
Rufiel  advises  the  insertion  of  a  trocar,  to  be  carried  through 
the  gum,  so  as  to  form  a  counter  opening.  Through  this,  in  a 
case  which  he  treated,  he  passed  a  seton,  and  it  remained  six 
weeks ;  at  the  expiration  of  this  time,  a  cure  was  accomplished. 
This  practice  has  been  followed  by  Callisen,  Zang,  Busch,  Henkle, 
Bertrandi,  Faubert  and  others.  Callisen  states  that  when  the 
tumor  points  in  the  palatine  arch  and  fluctuation  is  felt,  the  arti- 
ficial opening  should  be  formed  there.  Gooch,  in  a  case  which 
he  treated,  advised  the  perforation  of  the  antrum  through  the 
nasal  surface,  and  fixing  in  the  opening  a  canula  of  lead.  We 
are  also  informed  by  the  same  author,  that  Acrel,  after  having 
operated  in  the  manner  proposed  by  Cowper,  inserted  a  second 
canula  into  a  sinus  through  a  fistulous  opening  formed  in  the 
nose.     The  method  attributed  to  Weinhold,  consists  in  penetrat- 


TREATMENT    OF    PURULENT    SECRETIONS,    ETC.  521 

ing  the  sinus  from  the  upper  and  external  part  of  the  canine 
fossa,  with  the  instrument  directed  obliquely  downward  and  out- 
ward, so  as  to  avoid  the  branches  of  the  infra-orbital  nerve ; 
and  then  placing  a  little  lint  in  the  opening  thus  made.  Wein- 
hold  directs,  that  when  the  antrum  has  no  other  opening,  the 
instrument  should  be  carried  entirely  through  the  palatine  arch, 
and  then  by  means  of  a  curved  needle  and  thread,  he  introduces 
a  roll  of  lint,  saturated  or  covered  with  some  appropriate  medi- 
cine, and  this,  he  designs  to  act  as  a  seton. 

Velpeau  says,  the  perforation  is- effected  "in  the  point  of  elec- 
tion or  of  necessity.  The  first  varies  according  to  the  ideas  of 
the  operator :  circumstances,  on  the  contrary,  determine  the 
second.  In  cases  of  abscess,  dropsy,  fistula,  and  ulceration,  the 
operation  is  almost  always  performed  in  the  place  of  election. 
Provided  one  of  the  molar  teeth  be  unsound,  it  must  be  ex 
tracted,  together  with  the  adjoining  tooth ;  the  gum  is  then  to  be 
cut  down  to  the  bone,  externally,  internally,  behind  and  before, 
forming  a  kind  of  square  flap,  and  to  be  completely  detached 
from  the  surrounding  tissues ;  after  this  the  alveolus  is  to  be  per- 
forated with  the  instruments  of  Desault,  and  an  opening  made 
large  enough  to  admit  the  finger  into  the  sinus."  For  the  evacua- 
tion simply  of  purulent  mucus,  or  accumulated  fluids,  we  believe 
with  Boyer,  that  the  opening  should  always  be  made  from  be- 
neath ;  and  we  are  the  more  convinced  of  the  importance  of 
giving  the  alveolus  of  an  extracted  tooth  the  preference,  from 
the  consideration  that  it  is  to  the  irritation  produced  by  some 
one  or  more  of  these  organs,  that  the  diseases  of  this  cavity  are 
attributable.  Even  though  a  fistula  may  have  formed  above  the 
alveolar  ridge,  beneath  the  cheek,  or  in  the  palatine  arch,  we 
should  not  neglect  to  extract  such  teeth,  whether  carious  or 
sound,  as  may  be  productive  of  irritation.  It  may  not  always 
in  such  cases  be  necessary  to  perforate  the  sinus  from  the  socket 
of  a  tooth,  though  the  cure,  in  most  instances,  is  expedited  by  it. 

Jourdain,  an  eminent  French  dentist  and  graduate  in  surgery, 
instead  of  seeking  egress  for  matter  accumulated  in  the  maxil- 
lary sinus  by  any  of  these  methods,  proposed,  in  a  memoir  pre- 
sented to  the  Academy  in  1765,  to  probe  the  cavity  by  its  natu- 
ral opening,  and  then,  by  suitable  injections,  to  restore  it  to 
health.  The  Academy  gave  this  proposition  a  careful  attention, 
34 


522      TREATMENT  OF  PURULENT  SECRETIONS,  ETC. 

and  thoroughly  discussed  it.  The  practicability  of  obtaining 
entrance  into  the  sinus  in  this  way  was  called  in  question,  and 
it  was  contended  that  the  difficulties  presented  by  the  peculiar 
structure  of  the  parts  were  such  that  they  would  seldom  be  over- 
come.    The  practice  has  been  wholly  abandoned. 

When  the  natural  opening  is  closed,  the  first  indication,  as 
has  been  stated,  is  the  evacuation  of  the  matter;   and  for  this 
purpose,  a  perforation  should  be  made  into  the  sinus,  and  the 
most  proper  place  for  effecting  this,  it  has  been  shown,  is  through 
the  alveolar  cavity  of  the  second  molar.     It  may,  however,  be 
penetrated  from  that  of  either  of  the  other  molars  or  bicuspids. 
The  perforation,  after  the  extraction  of  the  tooth,  is  made 
with  a  straight  trocar,  which  will   be  found  more    convenient 
than  those  usually  employed  for  the  purpose.     The  point  of  the 
instrument,  having  been  introduced  into  the  alveolus   through 
which   it   is   intended   to   make   the   opening,  should  be  pressed 
against   the  bottom  of  the   cavity  in   the   direction   toward  the 
centre  of  the  antrum.     A  few  rotary  motions  of  the  instrument 
will  suffice  to  pierce  the  intervening  plate  of  bone.*    If  the  first 
opening  be  not  sufficiently  large,  its  dimensions  may  be  increased 
to  the  necessary  size  by  means  of  a  spear-pointed  instrument.  The 
entrance  is  usually  attended  wdth  a  momentary  severe  pain,  and 
the  withdrawal  of  the  instrument  followed  by  a  sudden  gush  of 
fetid  mucus.     In  introducing  the  trocar,  care  should  be  taken 
to  prevent  a  too  sudden  entrance  of  the  instrument  into  the 
cavity.     Without  this  precaution,  it  might  be  suddenly  forced 
against  the  opposite  wall.     It  is  not  always  necessary  to  perfo- 
rate the  floor  of  the  antrum  after  the  extraction  of  the  tooth; 
it  occasionally  happens,  as  has  already  been  remarked,  that  some 
of  the  alveolar  cavities  communicate  with  it. 

An  opening  having  thus  been  effected,  it  should  be  prevented 
from  closing  until  a  healthy  action  is  established  in  the  lining 
membrane,  and  for  this  purpose,  a  bougie,  or  leaden  or  silver 
canula,  may  be  inserted  into  the  opening  and  secured  to  one  of 
the  adjacent  teeth.  It  should,  however,  be  removed  for  the 
evacuation  of  the  secretions  at  least  twice  a  day.     The  forma- 

*•  In  a  cullcftitm  of  nearly  oue  hundred  superior  maxilliV!,  presented  to  the  Museum 
of  the  Baltimore  Dental  College,  bj'  Dr.  Maj'nard,  the  floor  of  the  antrum  varies  in 
thickness,  from  that  of  tissue  paper  to  half  an  inch. 


TKEATMENT  OF  PURULENT  SECRETIONS,  ETC.      523 

tion  of  an  opening  at  the  base  or  most  dependent  part  of  the 
sinus  will,  in  those  cases  where  a  fistula  has  been  previously 
formed,  be  followed,  in  most  instances,  by  its  speedy  restoration. 
Having  proceeded  thus  far,  the  cure  will  be  aided  by  the  em- 
ployment of  such  general  remedies  as  may  be  indicated  by  the 
state  of  the  general  health ;  and  for  the  dispersion  of  the  local 
inflammation,  leeches  to  the  gums  and  cheek  will  be  found  ser- 
viceable. The  antrum  may,  in  the  meantime,  be  injected  with, 
at  first,  some  mild  or  bland  fluid,  and  afterward  with  gently 
stimulating  liquids.  Dilute  port  wine,  a  weak  solution  of  the 
sulphate  of  zinc  and  rose  water,  and  also  that  of  copper  and  rose 
water,  have  been  recommended.  Diluted  tincture  of  myrrh  may 
sometimes  be  advantageously  employed,  and  when  the  membrane 
is  ulcerated,  a  solution  of  nitrate  of  silver  will  be  highly  service- 
able. The  author  has  used  a  solution  of  iodide  of  potassium 
with  advantage ;  also  a  weak  alcoholic  solution  of  tannic  acid. 
For  correcting  the  fetor  of  the  secretions,  a  weak  solution  of  the 
chlorinated  soda  or  lime  may  be  occasionally  injected  into  the 
antrum. 

In  cases  of  simple  muco-purulent  secretion,  a  weak  decoction 
of  galls  may  be  injected  into  the  sinus  with  advantage.  In- 
jections of  a  too  stimulating  nature  are  sometimes  employed. 
This  should  be  carefully  guarded  against,  by  making  them  at 
first  weak,  and  afterwards  increasing  their  strength  as  occasion 
may  require  ;  and  if  symptoms  of  a  violent  character  are  by  this 
means  produced,  they  should  be  combated  by  applying  leeches 
to  the  gums  and  fomentations  to  the  cheek. 

Dependent  as  these  afiections  in  most  instances  arc,  upon 
local  irritants,  greater  reliance  is  to  be  placed  on  their  removal 
and  giving  vent  to  the  acrid  puriform  fluids,  than  on  any  thera- 
peutical effects  exerted  upon  the  cavity  by  injections.  As  adju- 
vants, they  are  serviceable,  but  a  cure  cannot  be  effected  while 
the  exciting  cause  remains  unremoved. 

The  following  cases  may  serve  to  illustrate  the  treatment 
usually  pursued  in  this  disease. 

Case  1st.  Mrs.  T.,  a  married  lady,  about  forty  years  of  age, 
of  a  bilious  temperament,  applied  to  the  author  for  advice,  in 
1858.  She  had  suffered  from  neuralgic  pains  in  her  face  and 
temples,  at  intervals,  for  nearly  twenty  years,  and  as  ail  of  her 


524  TREATMENT    OF   PURULENT    SECRETIONS,    ETC. 

teeth,  especially  of  the  upper  jaw,  were  so  much  decayed  as  to 
preclude  the  possibility  of  restoration,  he  urged  their  immediate 
removal.  She  submitted  to  the  operation,  hoping  that  it  would 
relieve  her  from  the  pain  to  which  she  had  so  long  been  a  mar- 
tyr, and  intending  to  have  the  lost  organs  replaced  with  an  arti- 
ficial set.  She  called  again  in  a  few  months,  partly  for  this 
purpose  and  partly  to  obtain  relief  from  pain  which  she  still  ex- 
perienced. It  was  not  now  so  much  diffused  as  formerly,  but 
was  almost  wholly  confined  to  the  left  side  of  the  face.  On 
inquiry,  it  was  ascertained  that  fetid  matter  was  occasionally 
discharged  from  the  nostril  of  the  affected  side.  This  led  him 
to  suspect  that  the  antrum  was  diseased.  An  opening  was  ac- 
cordingly made  through  the  alveolar  border,  at  the  point  origi- 
nally occupied  by  the  secon^  molar.  The  withdrawal  of  the  in- 
strument was  followed  by  the  discharge  of  a  small  quantity  of 
purulent  matter.  The  antrum  was  now  forcibly  injected  with 
water.  This  caused  the  discharge  of  more  than  two  table-spoon- 
fuls of  hardened  flocculi  from  the  left  nostril,  which  from  long 
confinement,  were  insufferably  offensive.  The  injection  was  re- 
peated until  the  antrum  was  completely  freed  from  this  accumu- 
lation. A  solution  of  sulphate  of  zinc,  in  the  proportion  of  six 
grains  to  the  ounce  of  water,  was  now  substituted.  The  sinus 
was  injected  daily  with  this  for  a  little  more  than  a  week,  and 
without  any  other  treatment  a  complete  cure  was  effected. 

The  particulars  of  the  following  case  are  obtained  from  "  Ob- 
servations of  Bordenave  on  the  Diseases  of  the  Maxillary 
Sinus,"*  a  paper  embodying  reports  of  forty  highly  interesting 
cases. 

Case  2d.  "In  1756,"  says  our  author,  "I  was  consulted  by 
a  lady  whose  right  cheek  was  tumefied.  About  a  month  pre- 
viously she  had  experienced  acute  pain  under  the  orbit  of  the 
affected  side ;  and  she  had  felt  a  pulsation  and  heat  in  the  in- 
terior of  the  sinus,  and  the  maxillary  bone  was  slightly  elevated. 
These  signs  determined  me  to  propose  the  extraction  of  the  first 
molar  tooth  and  the  perforation  of  the  antrum  through  the  alve- 
olus. The  operation  was  followed  by  a  discharge  of  purulent 
matter,  the  sinus  was  afterwards  injected,  the  maxilla  gradually 
reduced  itself,  and  a  cure  was  effected  in  about  two  months." 

*  Mem.  de  I'Acad.  Royale  de  Chirurg.,  vol.  xii,  obs.  3,  p.  10. 


TREATMENT  OF  PURULENT  SECRETIONS,  ETC.      525 

Although  injections  were  employed  in  the  above  case,  it  was 
no  doubt  the  escape  of  the  matter  contained  in  the  antrum  to 
which  the  cure  was  attributable.  As  regards  the  cause  that  gave 
rise  to  the  affection  in  the  jSrst  instance,  not  a  single  word  is  said. 
It  may  have  resulted  from  inflammation,  lighted  up  in  the  sockets 
of  one  or  more  teeth,  and  progagated  from  thence  to  the  mucous 
membrane  of  this  cavity,  or  from  inflammation  produced  by 
some  other  cause,  and  a  consequent  obliteration  of  the  nasal 
opening. 

The  following  brief  statement  ia  taken  from  the  history  of  a 
case  narrated  by  Fauchard.* 

Case  3d.  The  child  of  M.  Galois,  set.  twelve  years,  whose 
first  right  superior  molar  was  decayed,  had  a  tumor  situated 
anteriorly  upon  the  upper  jaw  of  the  same  side,  extending  up  to 
the  orbit.  M.  Fauchard,  supposing  this  tumor,  which  was  about 
the  size  of  a  small  egg,  had  been  caused  by  the  carious  tooth  in 
question,  determined  on  its  extraction  as  the  only  means  of 
effecting  a  speedy  and  certain  cure,  and  the  result  proved  his 
opinion  correct.  The  removal  of  the  tooth  was  followed  by  a 
large  quantity  of  yellow  serous  matter,  which,  on  examination, 
was  found  to  have  escaped  from  the  antrum.  The  tumor  disap- 
peared soon  after  the  discharge  of  the  matter,  and  a  complete 
cure  was  effected. 

Bordenave,  in  noticing  the  foregoing  case,  does  not  believe 
that  the  tumor  communicated  with  the  maxillary  sinus,  for  the 
reason  that  the  matter  escaped  through  the  alveolus  of  the  first 
molar  immediately  after  its  extraction.  He,  however,  admits 
that  the  acumen  and  knowledge  of  Fauchard  are  such  as  to  have 
prevented  deception  in  the  case.  Admitting,  then,  the  state- 
ment to  be  correct — and  surely  the  circumstance  mentioned  by 
Bordenave  does  not  in  the  least  tend  to  invalidate  it,  for  it  is  of 
frequent  occurrence — a  cure  was  effected  simply  by  the  removal  of 
a  decayed  tooth,  to  the  irfitation  produced  by  which  the  disease 
was  undeniably  attributable.  The  two  following  cases  arc  de- 
scribed at  length  by  the  last  named  author  in  the  "  Memoires  de 
I'Academie  Royale  de  Chirurgie."t 

Case  4th.     A  woman,  in  1731,  had  the  first  superior  molar, 

*  Le  Chirurgien  Dentiste,  torn,  i,  obs.  8,  p.  483. 

t  Vol.  xii,  12mo,  Observations  5  and  6,  pp.  12  and  19. 


526      TREATMENT  OF  PURULENT  SECRETIONS,  ETC. 

the  crown  of  wluch  had  been  destroyed  by  caries,  extracted. 
Not  many  days  after  the  operation,  she  was  attacked  with  pain 
in  the  upper  jaw,  which  extended  from  the  maxillary  fossa  to 
the  orbit.  The  pain  was  so  great  as  to  deprive  her  of  rest,  but 
there  was  no  tumefaction  of  the  cheek  or  gums.  An  opening 
through  the  alveolus  into  the  sinus  was  discovered,  into  which  a 
probe  was  introduced  by  a  surgeon.  The  withdrawal  of  this  was 
followed  by  a  discharge  of  yellow  fetid  matter.  M.  Lamourier, 
who  was  afterwards  consulted,  removed  from  the  opening  a  tooth 
that  had  been  thrust  into  the  antrum  and  prevented  the  egress 
of  the  matter,  which,  by  its  retention,  had  become  purulent. 
Injections  were  employed,  a  part  of  which,  at  the  expiration  of 
thirty  days,  escaped  from  the  nasal  opening.  A  perfect  cure 
was  soon  after  effected. 

In  this  case,  the  affection  of  the  sinus  was  evidently  the  result 
of  the  injury  inflicted  upon  the  socket  of  the  first  superior  molar, 
in  an  attempt  at  the  extraction  of  the  tooth.  The  inflammation 
excited  by  this,  and  by  the  presence  of  the  tooth  that  had  been 
thrust  into  the  antrum,  extended  itself  to  the  lining  membrane 
of  this  cavity,  and  caused  a  temporary  obliteration  of  the  nasal 
opening,  so  that  to  effect  a  cure  it  was  necessary  to  obtain  free 
vent  for  the  retained  matter.  In  restoring  to  a  healthy  action 
the  mucous  membrane  of  the  cavity,  the  injections  may  have 
been  serviceable. 

Case  5th.  A  girl,  rot.  twenty-six  years,  had  a  very  much 
decayed  and  painful  superior  dens  sapientiae  on  the  right  side 
extracted;  the  tooth  was  broken,  and  all  the  roots  but  one  were 
left  in  their  sockets.  These  caused  an  abscess  to  form,  and  this 
was  followed,  for  a  short  time,  by  a  subsidence  of  the  pain; 
which,  however,  soon  returned,  and  a  dull,  heavy  sensation  was 
felt  in  the  antrum  of  the  affected  side.  From  thence  the  pain 
extended  to  the  eye  and  ear.  The  gums  at  length  became  tume- 
fied, and  the  pain  less  constant;  the  patient  remained  in  this 
condition  for  five  years,  during  which  time  five  teeth  were  ex- 
tracted. At  this  time  (1756),  M.  Beaupreau,  who  was  consulted, 
found,  on  examination,  that  the  gums  where  the  first  tooth  had 
been  extracted  had  not  entirely  united,  and  a  small  tubercle  had 
formed,  from  which  a  fluid  of  a  bad  smell  and  reddish  color  was 
discharging  itself.    He  introduced  a  probe  into  the  fistulous  hole 


TREATMENT    OF    PURULENT    SECRETIONS,    ETC.  527 

of  the  tubercle,  which,  after  having  overcome  some  obstacle  that 
at  first  impeded  its  passage,  penetrated  the  antrum.  The  open- 
ing was  enlarged  and  mercurial  water  applied  to  the  carious 
bone;  but  it  soon  closed,  and  the  pain,  which  had  ceased,  re- 
turned. Injections  then  were  resorted  to,  which  discharged 
themselves  in  part  through  the  nasal  opening,  and  the  patient 
continued  in  this  way  until  an  exfoliation  of  the  bone  took  place, 
when  a  cure  was  eflFected. 

The  cause  of  the  disease  in  this,  as  in  the  preceding  cases, 
was  alveolo-dental  irritation,  and  a  cure  Avould  at  once  have  been 
accomplished  by  the  removal  of  the  roots  of  the  tooth  that  had 
been  left  in  their  sockets ;  this  was  proven  by  the  fact  that  it 
was  not  until  they  were  thrown  off  with  their  exfoliated  alveoli, 
that  the  disease  was  subdued. 

In  alluding  to  these  and  similar  cases,  Bordenave  concludes 
there  are  not  many  cases  where  the  extraction  of  teeth  simply, 
will  suffice  to  effect  a  cure.  This  inference,  to  say  the  least  of 
it,  is  unfair;  for  in  the  case  last  given,  the  disease  was  attribu- 
table to  the  presence  of  the  roots  of  a  tooth  that  had  been  frac- 
tured in  an  attempt  to  extract  it,  and  left  in  their  sockets,  and 
we  have  good  reason  to  believe  that  the  cure  was  wholly  owing 
to  their  removal. 

The  history  of  the  following  exceedingly  interesting  case, 
which  was  communicated  to  the  Faculty  of  Medicine  by  Pro- 
fessor Dubois,  is  contained  in  the  eighth  number  of  their  bul- 
letin for  the  year  1813,  and  also  in  Buyer's  work  on  Surgical 
Diseases. 

Case  6th.  Upon  a  child  between  seven  and  eight  years  old,~ 
at  the  base  of  the  ascending  apophysis  of  the  superior  maxillary 
bone,  a  small  hard  round  tumor  of  the  size  of  a  walnut  was  per- 
ceived by  its  parents.  About  a  year  after,  the  child  fell  upon 
its  face,  and  caused  a  considerable  discharge  of  matter  from  its 
nose,  at  the  same  time  bruising  the  tumor.  No  other  injury 
was  received,  and  the  tumor  did  not  increase  perceptibly  in  size 
from  the  eighth  to  the  fifteenth  year.  During  the  next  year, 
however,  it  sensibly  augmented,  and  from  the  sixteenth  to  the 
eighteenth  year,  it  attained  so  great  a  volume,  that  the  floor  of 
the  orbit  Avas  elevated,  which  caused  a  diminution  in  the  size  of 
the  eye,  and  restricted  the  motions  of  the  eyelids.     The  arch  of 


528  TREATMENT   OF    PURULENT    SECRETIONS,    ETC. 

the  palate  was  depressed,  and  the  nasal  fossa  almost  closed. 
The  nose  was  forced  to  the  right  side  of  the  upper  part  of  the 
tumor,  and  there  was  a  considerable  elevation  beneath  the  sub- 
orbital fossa.  The  skin  below  the  inferior  eyelid  was  of  a  violet 
red  color,  and  very  tense.  The  upper  lip  was  elevated,  and  the 
gums  on  the  left  tide  protruded  beyond  those  on  the  other  side 
of  the  arch.  Respiration  was  painful,  and  the  patient  spoke 
with  difficulty.  Sleep  was  laborious,  and  mastication  was  at- 
tended with  pain.  "In  this  state,"  says  M.  Boyer,  "he  was 
seen  by  M.  Dubois,  September  1st,  1802;  but  as  he  was  not 
able  to  determine  on  the  proper  operation,  M.  Sabatier,  M.  Pe- 
letan  and  himself  were  called  in.  It  was  the  opinion  of  all, 
that  there  was  a  fungous  tumor  of  the  antrum,  and  for  the  re- 
moval of  this,  M.  Dubois  was  requested  to  make  choice  of  his 
own  method  of  operating. 

A  fluctuation  was  felt  behind  the  upper  lip,  and  this  deter- 
mined M.  Dubois  to  commence  the  operation  by  making  an 
incision  there,  which  was  followed  by  the  discharge  of  a  large 
quantity  of  a  glairy,  lymphatic  substance.  Through  this  opening 
a  sound  was  introduced  into  the  antrum,  and  to  M.  Dubois'  sur- 
prise, this  cavity  contained  no  tumor ;  but  upon  moving  the 
sound  about,  it  struck  upon  a  hard  substance,  in  the  most  elevated 
part  of  the  sinus,  which,  on  being  removed,  proved  to  be  a 
canine  tooth.  Preparatory,  however,  to  its  extraction,  two  in- 
cisors and  one  molar  were  removed  and  their  alveoli  cut  away. 
Injections  were  afterwards  employed,  and  the  patient  was  soon 
restored  to  health. 

It  is  not  necessary  to  stop  to  inquire  how  this  tooth  got  into 
the  antrum  ;  aberrations  of  this  sort  in  the  growth  of  the  teeth 
are  frequently  met  with,  and  some  precisely  similar  instances 
have  already  been  referred  to.* 

In  all  the  cases  which  have  as  yet  been  noticed,  the  affection 
was  traceable  to  local  irritation,  and  in  all,  except  the  last,  it 
originated  in  the  alveolar  ridge.  The  following  case  of  muco- 
purulent engorgement  may  be  thought  by  some  to  have  been 
occasioned  by  a  different  cause.  Yet,  there  are  circumstances 
connected  with  the  history  of  even  this  case,  that  go  to  justify 
the  belief,  that  if  the  teeth  had  been  in  a  healthy  condition  the 
aflfection  would  not  have  existed. 

*  Mem.  de  TAcademie  de  Chirurg.,  vol.  v,  Mem.  257. 


TREATMENT    OF    PURULENT    SECRETIONS,    ETC.  529 

Case  7th.  Mr.  G ,  a  laborer,  about  thirty  years  okl,  of  a 

decidedly  scorbutic  habit,  applied  in  the  spring  of  1834,  to  an 
eminent  physician  of  Baltimore,  to  obtain  his  advice  concerning 
an  affection  of  the  left  side  of  his  face,  under  which  he  had  been 
laboring  for  several  months.  The  physician  after  having  ex- 
amined the  case,  came  to  the  conclusion,  that  it  was  mucous  en- 
gorgement of  the  maxillary  sinus,  and  requested  him  to  call 
upon  us,  and  have  one  of  his  molar  teeth  extracted,  and  the  floor 
of  the  antrum  pierced  through  its  alveolus.  He  at  the  same 
time  desired,  that  if  his  opinion  in  regard  to  the  nature  of  the 
disease  proved  to  be  correct,  we  should  take  charge  of  the  case 
altogether.  On  examining  his  mouth,  we  discovered  that  nearly 
all  the  teeth  of  both  jaws,  the  gums  and  alveoli,  were  extensively 
diseased,  and,  on  inquiry,  obtained  from  him  the  following 
statement  with  regard  to  the  commencement  and  progress  of  the 
affection. 

About  six  months  before  this  time,  having  been  exposed, 
while  pursuing  his  ordinary  avocations,  to  very  inclement  and 
changeable  weather,  he  contracted  a  severe  cold  ;  in  consequence 
of  this  he  was  confined  to  his  bed  for  several  days,  during 
which  time,  he  was  twice  bled,  took  two  cathartics,  and  other 
medicines. 

The  disease  at  first  settled  in  his  head,  face,  and  jaws,  but  at 
the  expiration  of  eight  or  ten  days,  was  subdued  by  the  above 
treatment,  with  the  exception  of  the  pain  in  his  left  cheek,  and 
soreness  in  the  upper  teeth  of  the  same  side.  The  pain  in  his 
cheek,  although  not  constant,  still  continued ;  the  nasal  cavity 
of  that  side  ceased  to  be  supplied  with  its  usual  secretion,  the 
teeth  became  more  sensitive  to  the  touch  ;  finally,  at  the  end  of 
four  months,  a  slight  protuberance  of  the  cheek  Avas  observable, 
accompanied  by  a  tumor  upon  the  left  side  of  the  palatine  arch, 
which,  when  we  first  saw  him,  had  attained  to  half  the  size  of  a 
black  walnut ;  and  it  was  by  the  fluctuation  felt  here,  that  the 
physician  whom  he  first  consulted,  was  induced  to  suspect  the 
true  nature  of  the  disease. 

Acting  in  consultation  with  the  medical  gentleman  in  whose 
care  the  patient  had  placed  himself,  we  extracted  the  second  left 
superior  molar  ;  then  through  its  alveolus  penetrated  the  antrum 
by  means  of  a  straight  trocar,  after  the  withdrawal  of  which,  a 


530      TREATMENT  OF  PURULENT  SECRETIONS,  ETC. 

large  quantity  of  glairy,  fetid  mucous  fluid  was  discharged.  The 
perforation  was  kept  open  by  means  of  a  bougie,  secured  with  a 
silk  ligature  to  an  adjoining  tooth,  as  recommended  by  Des- 
champs,  and  the  antrum  injected  three  times  a  day,  at  first 
simply  with  rose  Avater,  to  which  a  small  quantity  of  sulphate  of 
zinc  was  afterwards  added.  By  this  treatment,  the  lining  mem- 
brane of  the  antrum,  at  the  expiration  of  five  weeks,  was  re- 
stored to  health,  and  the  secretions  that  escaped  through  the 
perforation,  no  longer  exhaled  a  fetid  odor. 

The  patient,  not  experiencing  any  inconvenience,  withdrew 
the  bougie,  and  allowed  the  aperture  to  close.  In  about  two 
months,  he  again  presented  himself  to  the  author  similarly 
affected  as  when  he  first  saw  him.  He  now  extracted  the  first 
superior  left  molar,  and  perforated  the  antrum  through  the  alve- 
olus, and  a  quantity  of  fetid  mucous  fluid  was  again  discharged ; 
the  dens  sapientite,  and  the  first  and  second  bicuspids  of  the 
aifected  side,  being  carious,  were  also  extracted.  Injections  of 
sulphate  of  zinc  and  rose  water,  diluted  tincture  of  myrrh,  di- 
luted port  wine,  and  a  decoction  of  nut  galls,  were  alternately 
employed  for  three  months ;  at  the  expiration  of  this  time,  the 
nasal  opening,  which  had  been  previously  closed,  was  re-estab- 
lished, and  a  perfect  cure  eff'ected. 

The  condition  of  the  teeth  in  the  case  just  narrated,  may  not 
be  thought  to  have  exerted  any  agency  in  the  production  of  the 
affection  of  the  antrum,  but  the  following  considerations  would 
seem  to  justify  a  different  conclusion.  The  presence  of  decayed 
teeth  beneath  the  sinus,  may  not  only  have  contributed  to  ag- 
gravate the  morbid  action  lighted  up  by  the  cold  which  he  had 
taken,  but  may  also  have  caused  it  to  locate  itself  in  this  cavity ; 
and  the  fact  that  the  inflammation  of  the  lining  membrane  and 
the  obliteration  of  the  nasal  opening  continued  until  they  were 
removed,  would,  at  least,  seem  to  warrant  such  an  inference. 
Th'at  the  injections  w'ere  beneficial,  we  do  not  doubt,  but  that  the 
cure  was  effected  by  them,  no  one,  we  think,  will  dare  to  afiirm. 
We  are  far  from  believing  that  the  presence  of  the  decayed  teeth 
was  the  sole  cause  of  the  disease  of  the  antrum ;  that  they  con- 
tributed to,  and  protracted  it,  we  cannot  hesitate  to  believe  ;  still, 
but  for  the  increased  excitability,  and,  perhaps,  actual  inflamma- 
tion, induced  in  the  mucous  membrane,  by  the  exposure  of  the 


? 


TREATMENT  OF  PURULENT  SECRETIONS,  ETC.      531 

patient  to  inclement  and  sudden  transitions  of  weather,  it  is  pro- 
bable the  sinus  Avould  never  have  become  affected.  But  on  the 
other  hand  we  think  it  not  unlikely  that,  although  the  disturb- 
ance may  have  been  originated  from  this  cause,  no  very  serious 
or  lasting  morbid  effect  would  have  been  produced,  if  the  teeth 
and  alveoli  had  been  in  a  perfectly  healthy  condition. 

The  particulars  of  the  following  highly  interesting  case  were 
communicated  to  the  author  by  Dr.  L.  Roper,  of  Philadelphia, 
in  a  conversation  which  he  had  with  him  in  1845. 

Case  8th.     Miss  M ,  a  young  lady  from  the  West  Indies, 

about  fourteen  years  of  age,  had  a  fistulous  opening  beneath  the 
right  orbit,  communicating  with  the  maxillary  sinus.  By  means 
of  a  probe  introduced  through  the  opening  into  this  cavity,  the 
apices  of  the  roots  of  the  first  superior  molar  could  be  distinctly 
felt. 

Medical  aid  was  sought  at  an  early  stage  of  the  disease,  but 
as  no  permanent  benefit  resulted  from  the  treatment  adopted,  the 
young  lady,  at  the  expiration  of  nine  months,  was  brought  by 
her  father  to  Philadelphia,  and  in  the  spring  of  1831,  placed 
under  the  care  of  the  late  Dr.  Physick.  He  suspecting  that  the 
affection  of  the  antrum  had  resulted  from  and  was  still  kept  up 
by  irritation,  produced  by  the  first  superior  molar  of  the  affected 
side  which  was  considerably  decayed,  directed  her  to  be  taken  to 
Dr.  Roper,  who,  concurring  with  him  in  opinion,  at  once  extracted 
the  carious  tooth.  The  operation  was  followed  by  the  immediate 
discharge  of  a  large  quantity  of  thick,  muddy,  and  greenish 
matter.  The  fistula  under  the  orbit  soon  closed,  and  without 
further  treatment,  a  perfect  cure  was  accomplished  in  the  course 
of  a  few  weeks. 

The  foregoing  are  all  the  particulars  which  we  could  obtain 
concerning  this  interesting  case.  We  have  no  doubt  that  if  all 
the  circumstances  connected  with  its  early  history  were  known, 
it  would  be  found  to  have  resulted  from  inflammation  of  the  lin- 
ing membrane  of  the  antrum,  caused  by  irritation  in  the  socket 
of  the  tooth  which  was  extracted.  This  opinion  is  sustained  by 
the  facts,  that  this  tooth  Avas  affected  with  caries,  and  that  its 
removal  was  followed  by  the  immediate  cure  of  the  disease. 

In  Bordenave's  collection  of  cases  of  disease  of  the  maxillary 
sinus,  published  in  the  Memoirs  of  the  Royal  Academy  of  Sur- 


532      TREATMENT  OF  PURULENT  SECRETIONS,  ETC. 

gery,  there  are  several  examples  similar  to  the  one  just  narrated. 
We  subjoin  a  description  of  the  two  following : 

Case  9th.  A  servant  of  the  Count  de  Maurepas  had  been 
afflicted  for  six  months  with  a  fistula  upon  the  left  cheek,  a  little 
below  the  orbit,  penetrating  to  the  maxillary  sinus,  and  caused 
by  the  spontaneous  opening  of  an  abscess.  The  first  and  second 
molars,  both  of  which  were  considerably  decayed,  were  extracted 
by  M.  Hevin.  As  there  were  no  openings  through  the  alveoli, 
he  perforated  one  with  a  trocar;  this  opening  gave  vent  to  a 
great  quantity  of  putrid  sanies,  and  did  not  close  for  more  than 
a  year  after  it  was  made.  The  fistula  of  the  cheek  healed  in 
about  ten  days. 

Case  10th.  In  1717,  a  soldier  of  the  regiment  of  Bassigny, 
who  had  for  a  long  time  a  fistula  in  his  cheek  penetrating  into 
the  maxillary  sinus,  was  treated  for  it  at  the  Hotel  Dieu,  of 
Montpelier.  The  matter  settling  near  the  orifice  of  the  fistula, 
prevented  it  from  closing.  M.  Lamourier,  on  examining  the 
mouth  of  the  soldier,  perceived  that  the  second  superior  molar 
was  decayed ;  this  he  extracted  and  profited  by  the  alveolar 
cavity  to  make  an  opening  into  the  base  of  the  sinus.  The 
fistula  of  the  cheek  was  by  this  means  cured  in  a  few  days,  but 
the  counter  opening  was  not  immediately  permitted  to  close. 

In  cases  of  fistula  resulting  simply  from  engorgement  of  the 
sinus,  the  treatment  should  consist,  as  in  the  foregoing  cases,  in 
the  formation  of  a  counter  opening,  which  should  always  be 
efiected  at  the  most  dependent  part  of  the  cavity ;  and  next  in 
the  removal  of  all  sources  of  local  irritation ;  lastly  in  the  em- 
ployment of  suitable  injections. 

In  the  cases  thus  far  presented,  we  have  selected  such  as  were 
not  complicated  with  abscess,  ulceration  of  the  lining  membrane, 
or  caries  of  the  surrounding  osseous  walls ;  but  to  the  existence 
of  the  two  last,  the  affections  of  which  we  have  been  treating 
often  give  rise.  Without  extending  our  remarks  further  upon 
mucous  engorgement  and  purulent  conditions  of  the  secretions  of 
this  cavity,  the  next  form  of  disease  on  which  we  propose  to 
speak,  is  abscess — an  affection,  differing  in  all  its  characteristics 
from  any  of  the  foregoing. 


CHAPTER    FOURTH. 
ABSCESS  OF  THE  MAXILLARY  SINUS. 

The  formation  of  abscess  in  any  other  part  of  the  maxillary- 
sinus  than  at  the  extremity  of  the  root  of  a  tooth  which  has 
penetrated  the  cavity,  is  exceedingly  rare.  There  are  on  record 
but  two  well  authenticated  cases  in  which  it  has  happened,  so 
far  as  Ave  have  been  able  to  ascertain.  One  of  these  is  described 
by  Mr.  Thomas  Bell,*  and  the  other  by  Borden ave.f  The 
abscess  in  both  instances  was  seated  in  the  upper  part  of  the 
antrum,  beneath  the  orbit.  But  as  we  shall  have  occasion  to 
refer  to  these  cases  again,  it  is  not  necessary  to  say  more  con- 
cerning them  at  this  time. 

Dr.  Hullihen,  in  an  article  in  the  second  volume  of  the  Ameri- 
can Journal  of  Dental  Science,  contends  that  antral,  as  well  as 
alveolar  abscess  consists  in  the  effusion  of  pus,  formed  in  the 
pulp-cavity  of  a  tooth,  between  the  bone  and  lining  membrane. 
That  this  view  of  the  subject  is  incorrect,  is  proven  by  the  fact, 
that  abscess  is  almost  as  frequently  formed  in  the  sockets  of  dead 
as  of  living  teeth.  The  matter  from  alveolar  abscess,  in  those  cases 
where  the  plate  of  bone  intervening  between  the  extremity  of 
the  root  of  a  superior  molar  or  bicuspid,  is  thinner  than  the  sur- 
rounding osseous  wall,  often  escapes  through  it  into  this  cavity, 
after  having  first,  as  Dr.  Hullihen  justly  remarks,  effused  itself 
between  the  bone  and  lining  membrane.  In  this  case,  it  cannot 
properly  be  termed  an  abscess  of  the  antrum.  Although  the 
matter  escapes  into  this  cavity,  and,  in  consequence,  becomes  in- 
volved in  disease ;  yet  the  disease  having  originated  in  the  alveo- 
lus of  a  tooth,  which  is  still  its  principal  seat,  is,  in  the  strictest 
sense  of  the  term,  alveolar  abscess.  It  sometimes  happens  that 
pus  from  an  abscess,  formed  in  the  socket  of  a  superior  molar, 
discharges  itself  into  this  cavity,  and  escapes  through  the  open- 

*  Anatomy,  Physiology  and  Diseases  of  the  Teeth. 

t  Mem.  de  I'Acad.  Royale  de  Chirurg.,  vol.  12,  12mo.  ed,  obs.  si.  p.  31. 


534  ABSCESS    OF   THE    MAXILLARY    SINUS. 

ing  into  the  nose.  A  pulp  may  suppurate,  and  the  matter  be 
confined  in  the  cavity  of  the  tooth  for  a  long  time ;  or  be  dis- 
charged through  a  decayed  opening  in  the  crown,  communicating 
with  the  internal  cavity,  without  causing  alveolar  abscess.  The 
purulent  matter  contained  in  the  sac  at  the  extremity  of  the  root 
of  a  tooth,  is  not  always  formed,  as  Dr.  Hullihen  supposes,  in 
the  cavity  of  the  tooth.  The  quantity  of  pus  discharged  from 
an  alveolar  abscess  is  often  greater  than  that  which  could  be 
formed  by  the  suppuration  of  the  soft  tissues  contained  within 
the  cavity  of  a  tooth  ;  and,  besides,  after  this  matter  has  been 
discharged,  it  cannot  again  be  reproduced  here ;  consequently, 
any  matter  which  may  afterwards  accumulate  in  the  cavity  of 
the  tooth,  must  be  secreted  by  the  soft  parts  about  the  extremity' 
of  the  root.  Again,  abscess  often  forms  at  the  extremity  of  the 
root  of  a  tooth,  after  their  internal  cavities  have  been  filled  to 
the  very  apex.  The  alveolo-dental  membrane  at  the  apex  of  the 
root  of  a  tooth,  around  the  nerve  cord,  is  more  vascular,  and 
endowed  with  greater  nervous  sensibility,  than  at  any  other  part, 
consequently,  the  inflammatory  action  here  is  always  greatest, 
and  it  is  here  that  suppuration  first  takes  place. 

The  apices  of  the  roots  of  the  first  and  second  superior  molars, 
when  they  do  not  actually  perforate  the  floor  of  the  antrum,  are 
often  above  its  level,  and  covered  by  only  a  very  thin  shell  or 
cap  of  bone  ;  hence,  although  abscess  in  one  of  the  teeth  is 
strictly  alveolar,  the  matter  is  more  liable  to  make  for  itself  a 
passage  into  this  cavity,  than  through  the  gum  into  the  mouth. 
When  this  happens,  it  gives  rise  to  inflammation  of  the  lining 
membrane,  causing  its  secretions  to  become  more  or  less  vitiated, 
and  often  leads  to  an  erroneous  opinion  concerning  the  true  seat 
of  the  disease. 

It  is  only  when  the  root  of  a  tooth  actually  penetrates  the  floor 
of  the  antrum,  or  its  apex  is  actually  situated  in  it,  that  the  dis- 
ease can  properly  be  said  to  be  abscess  of  the  antrum.  When  the 
root  does  penetrate  it,  the  tubercle  at  its  apex  around  the  nerve 
cord  and  blood  vessels,  is  between  the  lining  membrane  and  perios- 
teal tissue ;  both  of  which,  in  the  immediate  vicinity,  become  direct- 
ly involved  in  inflammation,  and  this  sometimes  extends  to  every 
part  of  the  cavity,  causing,  in  some  instances,  obliteration  of  the 
nasal  opening.     This,  however,  does  not  often  occur,  but  when 


SYMPTOMS    OF    ABSCESS.  535 

it  does,  is  followed  by  engorgement  of  the  sinus,  occasionally, 
by  ulceration  of  the  lining  membrane  and  disease  in  the  surround- 
ing parts. 

Sometimes  the  plate  of  bone  intervening  between  the  extremity 
of  the  root  of  a  tooth  around  which  a  tubercle  has  formed,  and 
the  antrum,  is  destroyed,  and  the  tubercle,  instead  of  being 
wholly  confined  Avithin  the  alveolus,  is  forced  up,  as  it  enlarges, 
almost  entirely  into  this  cavity.  The  inflammation,  after  hav- 
ing attained  a  certain  height,  is  succeeded  by  suppuration,  and 
the  secretion  of  pus  goes  on  until  the  sac  bursts,  when  the  mat- 
ter is  discharged,  and,  mixing  with  the  mucous  secretions  of  this 
cavity,  ultimately  escapes  with  them  through  the  nasal  opening 
into  the  nose. 

As  regards  the  morbid  effects  produced  upon  the  lining  mem- 
brane and  surrounding  bony  parietes  of  the  antrum,  by  an  ab- 
scess of  this  kind,  if  the  matter  be  discharged  there,  it  is  of  little 
consequence  whether  it  be  formed  in  the  cavity,  or  in  the  alveo- 
lus of  the  tooth  that  gave  rise  to  it.  The  effects  are  nearly  the 
same  in  one  case  as  in  the  other.  If  the  general  health  of  the 
patient  be  good,  and  the  natural  opening  of  the  sinus  remain 
pervious,  the  symptoms  seldom  assume  an  alarming  character ; 
but  under  other  and  less  favorable  circumstances,  the  most  dan- 
gerous and  aggravated  forms  of  disease  may  result  from  abscess 
in  either  place. 

SYMPTOMS. 

In  the  incipient  or  formative  stages  of  abscess  of  the  maxillary 
sinus,  the  symptoms  are  similar  to  those  that  characterize  in- 
flammation of  the  lining  membrane,  or  violent  inflammatory 
tooth-ache.  The  pain  is  generally  most  severe  in  the  upper  part 
of  the  alveolar  ridge,  above  one  of  the  molar  or  bicuspid  teeth. 
From  thence,  it  often  extends  to  the  lower  parf  of  the  orbit,  the 
ear,  temple,  muscles  of  the  cheek  and  scalp.  It  is  more  or  less  con- 
stant, and  a  throbbing  sensation  is  felt  high  up  in  the  alveolar 
border  beneath  the  cheek.  If  the  abscess  is  seated  at  the  apex 
of  the  root  of  a  tooth,  this  organ  will  appear  slightly  elongated 
and  sore  to  the  touch ;  the  cheek,  in  most  instances,  is  slightly 
tumefied,  and  more  or  less  flushed.     If  the  abscess  is  seated  in 


536  CAUSES    OF    ABSCESS. 

any  other  part  than  the  base  of  the  antrum,  the  symptoms  may 
differ  in  some  respects  from  the  foregoing. 

The  pain,  after  having  continued  for  several  days,  is  succeeded 
by  suppuration,  when  it  immediately  subsides.  Slight  paroxysms 
of  heat  and  cold  are  now  felt,  and  if  the  natural  opening  of  the 
antrum  is  not  closed,  purulent  matter  will,  occasionally,  be  dis- 
charged. If  purulent  matter,  or  mucus  mixed  with  pus,  be  dis- 
charged from  the  nostril  of  the  affected  side,  when  the  patient  in- 
clines his  head  to  the  opposite  side,  or  makes  a  sudden  and  forci- 
ble expiration  through  it  while  the  other  is  closed,  the  existence 
of  abscess  in  this  cavity  will  be  very  conclusively  indicated. 

The  abscess  having  burst,  pus  will  be  discharged  from  time  to 
time,  for  several  days,  which  will  escape  through  the  nasal  open- 
ing, with  hardened  flocculi  or  other  matter,  and  will  then  very 
nearly  or  altogether  cease.  The  disease,  however,  if  the  irritant 
which  gave  rise  to  it  still  remains,  is  by  no  means  cured.  A  re- 
currence is  liable  to  take  place  every  time  the  patient  takes  cold, 
when  all  the  symptoms  just  described  will  be  again  experienced  ; 
and  each  succeeding  attack  leaves  the  parts  implicated  in  the 
disease  in  a  more  unhealthy  condition,  and,  as  a  consequence, 
more  susceptible  to  the  action  of  morbid  irritants.  Suppuration, 
also,  at  each  successive  attack,  takes  place,  and  the  pus  gradu- 
ally assumes  a  more  and  more  unhealthy  character. 

CAUSES. 

It  will  not  be  necessary  to  say  much  concerning  the  causes  of 
abscess  of  the  antrum.  It  is  sufficient  to  state,  they  are  the 
same  as  those  of  tooth-ache  ;  namely,  inflammation  of  the  alveolo- 
dental  periosteum  or  inflammation  of  the  lining  membrane  of  this 
cavity ;  to  the  presence  of  one  or  other,  or  both  of  these  it  18 
attributable.  These  may  be  occasioned  by  caries  of  the  teeth, 
or  a  dead  or  loose  tooth ;  or  by  a  blow  upon  the  cheek,  or  ex- 
posure to  sudden  changes  of  weather.  Other  causes  may  some- 
times be  concerned,  but  the  foregoing  are  the  principal,  and  all 
it  is  necessary  to  enumerate. 


TREATMENT    OF    ABSCESS.  537 


TREATMENT. 


In  the  treatment  of  abscess  of  tlie  maxillary  sinus,  as  •well  as 
that  of  a  muco- purulent  condition  of  its  secretions  or  engorge- 
ment, the  first  and  most  important  indication  is  to  obtain  vent 
for  the  matter  at  the  lowest  part  of  the  cavity.  The  best 
method  of  doing  this  has  been  described,  and  it  is  unnecessary 
to  recapitulate  the  directions  already  given  for  the  accomplish- 
ment of  this  object. 

The  formation  of  abscess  might,  however,  in  almost  every  in- 
stance he  prevented  by  the  timely  adoption  of  proper  treatment. 
On  the  occurrence  of  severe,  deep-seated  and  throbbing  pain  in 
the  upper  part  of  the  alveolar  ridge,  (or  just  above  it  in  the  re- 
gion of  the  antrum,  such  as  has  been  described  as  attending  the 
formation  of  abscess  in  this  cavity,  or  in  the  alveolus  of  a  superior 
molar,)  if  the  tooth  directly  beneath  the  place  where  it  was  first 
felt,  be  considerably  decayed,  or  its  lining  membrane  exposed, 
or  if  it  be  dead,  loose,  or  the  socket  much  diseased,  it  should  be 
immediately  extracted.  By  this  simple  operation,  the  formation 
of  abscess  not  only  in  the  socket,  but  also  in  the  antrum,  may, 
in  almost  every  instance,  be  prevented. 

The  curative  indications,  if  the  abscess  is  of  recent  formation, 
and  has  resulted  from  the  presence  of  a  diseased  tooth,  are  simi- 
lar to  the  preventive.  The  first  thing  to  be  done  is  to  remove 
the  tooth  that  caused  it,  and  if  this  operation  is  not  delayed  too 
long,  it,  in  most  instances,  will  be  all  that  is  necessary  to  effect 
a  cure.  In  addition  to  this.  Dr.  Hullihen  recommends  the  per- 
foration of  the  antrum  ;*  but  in  those  cases  where  the  abscess 
has  formed  at  the  apex  of  the  root  of  a  molar,  this  is  not  neces- 
sary ;  because  in  all  such  cases,  the  alveolus  communicates  with 
this  cavity,  so  that  on  the  removal  of  the  tooth,  there  will  be  a 
sufficiently  large  opening  communicating  with  it ;  besides  the 
tubercle  or  sac,  although  situated  within  the  sinus,  is  usually 
brought  away  with  the  tooth. 

When  the  abscess  has  been  of  long  standing,  and  the  lining 
membrane  of  the  antrum  has  become  seriously  affected,  in  addi- 

*  American  Journal  of  Dental  Science,  vol.  ii,  p.  182. 
35 


538  TREATMENT    OF    ABSCESS. 

tion  to  the  removal  of  the  tooth,  other  treatment  will  have  to  be 
resorted  to.  The  opening  into  the  antrum,  if  necessary,  should 
be  enlarged,  and  it  should  be  prevented  from  closing  until  the 
health  of  the  lining  membrane  is  restored.  For  the  promotion 
of  this,  injections,  such  as  have  been  already  recommended,  will 
be  found  serviceable. 

In  cases  of  simple  abscess  of  the  antrum,  seated  at  the  apex  of 
the  root  of  a  superior  molar,  we  have  never  found  it  necessary  to 
adopt  any  other  treatment  than  the  foregoing.  It  may,  how"ever, 
in  some  instances,  be  necessary  to  remove  more  than  one  tooth. 

We  might,  if  it  were  necessary,  give  the  history  of  several 
interesting  cases  of  abscess  of  this  cavity,  originating  at  the  ex- 
tremity of  the  roots  of  teeth  ;  but  as  the  treatment  is  so  simple, 
it  would  unnecessarily  enlarge  this  portion  of  our  work.  But 
before  we  conclude  our  remarks  upon  abscess  of  this  cavity,  we 
will  give  the  history  of  one  case  to  which  allusion  has  before  been 
made.  The  following  detailed  statement  we  quote  from  Mr. 
Bell's  treatise  on  the  teeth. 

Case  11th.  "Mary  B.,  aged  eighteen,  with  an  unhealthy 
and  somewhat  strumous  aspect,  of  languid  disposition,  and  of 
retiring  and  timid  habits,  came  under  my  care  on  the  3d  of  Jan- 
uary, 1817,  in  consequence  of  a  severe  and  continued  pain  on 
the  left  side  of  the  face,  of  a  dull,  heavy  character,  and  appa- 
rently deep-seated,  but  occasionally  darting  in  acute  paroxysms 
across  the  face  toward  the  nose.  The  cheek  was  swollen,  and 
the  palate  somewhat  enlarged.  About  a  year  before,  the  first 
superior  molar  of  that  side  had  been  extracted,  on  account  of 
severe  pain  in  the  face,  but  without  producing  any  relief;  the 
pain  was,  consequently,  attributed  to  rheumatism,  from  which 
complaint  she  had  long  suffered  to  a  great  degree  in  the  shoul- 
der, hip  and  other  joints,  and  for  which  she  had  been  under  the 
care  of  many  medical  practitioners,  both  in  London  and  Bath, 
having  been  sent  to  the  latter  place  for  the  use  of  the  waters. 
When  I  first  saw  her,  the  general  health  was  much  deranged: 
the  stomach,  bowels  and  liver  performed  their  functions  very 
imperfectly ;  and  the  uterus  partook  of  the  general  sluggishness 
of  the  system,  menstruation  being  almost  wholly  suppressed, 
and  the  periods  only  indicated  by  increased  indisposition,  and 
especially  by  an  exacerbation  of  the  pain  in  the  face. 


TREATMENT    OF    ABSCESS.  539 

"No  discharge  had  taken  place  from  the  nose,  but,  from  the 
nature  and  situation  of  the  pain,  the  direction  of  its  paroxysms, 
the  enlargement  of  the  cheek  and  palate,  and  from  an  occa- 
sional trifling  discharge  of  pus  from  the  alveolus  of  the  tooth 
which  had  been  extracted,  I  could  not  doubt  that  the  antrum 
was  the  seat  of  the  disease.  On  examining  the  teeth,  I  found 
that  the  second  bicuspid  was  also  diseased,  and  as  it  had  at  times 
occasioned  considerable  pain,  I  extracted  it,  with  the  view  of 
removing  every  possible  source  of  irritation. 

"Six  leeches  were  ordered  to  be  applied  to  the  face,  and  after- 
wards the  continued  application  of  a  cold  lotion.  Medicines 
were  also  administered  with  reference  to  the  general  health,  as 
regarded  both  the  digestive  and  the  uterine  functions;  and  on 
January  7th  I  determined  on  puncturing  the  antrum.  I  conse- 
quently introduced  the  trocar  through  the  anterior  alveolar 
cavity  of  the  first  molar,  and  found  that  when  the  instrument 
came  in  contact  with  the  lining  membrane,  the  most  acute  pain 
was  produced,  indicating  the  existence  of  a  high  degree  of  in- 
flammation in  that  structure.  On  withdrawing  the  trocar, 
when  the  antrum  was  freely  opened,  I  was  surprised  and  a  little 
disappointed  at  finding  that  not  the  smallest  discharge  made  its 
appearance.  There  was  a  small  quantity  of  glairy  mucus,  but 
nothing  more.  I  introduced  the  blunt  end  of  a  probe,  and 
found  that  the  opening  was  quite  free ;  but  on  passing  it  up- 
ward toward  the  orbit,  its  passage  was  restricted  by  a  firm 
elastic  substance,  which  gave  the  impression  that  a  solid  tumor 
existed  in  the  upper  part  of  this  cavity,  and  which  produced  in- 
tolerable pain  on  being  pressed  with  the  probe.  I  now  injected 
some  tepid  water,  and  found  that  the  nasal  opening  was  pervious, 
as  the  water  passed  freely  into  the  nose.  As  the  operation  had 
produced  a  considerable  increase  of  pain,  and  as  the  parts  ap- 
peared a  good  deal  inflamed,  I  ordered  six  leeches  to  be  applied, 
the  bowels  to  be  freely  opened,  and  an  opiate  to  be  taken  at 
night. 

"January  9th.  The  pain  had  been  extremely  severe  ever 
since  the  operation,  with  scarcely  any  mitigation,  excepting  for 
a  few  hours  after  the  application  of  the  leeches.  A  probe,  now 
introduced  into  the  antrum,  met  with  similar  resistance,  but 
much   nearer  the  orifice  than  before,  proving  that  the  tumor 


540  TREATMENT   OF    ABSCEsS. 

had  increased ;  and  on  injecting  warm  water,  it  no  longer  passed 
into  the  nose.  The  leeches,  the  aperient  and  the  opiate  were 
repeated. 

"January  11th.  The  pain  continued  without  cessation,  and 
no  sleep  was  produced  by  the  opium.  The  inflammation  appa- 
rently not  reduced ;  pulse  one  hundred,  small  and  feeble ;  the 
palate  a  little  enlarged,  but  not  more  so  than  might  be  accounted 
for,  by  the  thickening  of  the  integuments  from  inflammation. 
I  could  now  distinctly  feel  with  a  probe  that  the  tumor  was  not 
only  increased  in  size,  but  that  it  had  become  softer,  yielding  in 
some  measure  to  pressure,  and  conveying  the  impression  that  it 
contained  fluid.  I  therefore  introduced  a  sharp  pointed  instru- 
ment, which  with  a  little  force  pierced  the  tumor,  and  a  gush  of 
pus  instantly  took  place,  Avith  immediate  relief  to  the  patient. 

"  Here,  then,  was  a  sac  containing  pus,  existing  doubtless  as 
a  distinct  cyst,  the  result  of  inflammation  in  the  membrane ;  for 
it  is  scarcely  probable  that  the  membrane  itself  had  become 
separated  from  its  attachment  by  the  formation  of  pus  between 
it  and  the  bone.  That  the  former  was  .the  true  situation  of  the 
disease,  may  be  inferred  from  the  fact  that  no  subsequent  caries 
of  the  bone  took  place,  which  would,  undoubtedly,  have  been 
the  case,  had  the  matter  been  foi'med  in  contact  with  the  bone; 
and  it  could  scarcely  have  been  produced  between  the  mucous 
membrane  and  the  periosteum,  as  these  two  structures,  though 
essentially  distinct  from  each  other,  are  inseparably  connected. 

"The  pus  continued  to  be  discharged  for  a  day  or  two,  and 
then  entirely  ceased.  In  passing  the  probe,  a  week  after  the 
former  operation,  I  found  the  same  resistance  as  before,  and  in 
the  same  situation;  the  cyst  was  again  punctured,  and  again  the 
pus  was  discharged.  This  alternation  of  repletion  and  evacua- 
tion of  the  cyst  regularly  recurred  for  a  considerable  time,  but 
the  opening  into  the  nose  did  not  again  become  stopped.  The 
general  health,  however,  in  the  meanwhile,  improved,  and  the 
pain  in  the  face  was  greatly  diminished,  rctm-ning  only,  with 
any  degree  of  violence,  when  the  cyst  was  full. 

"At  length  the  repeated  perforation  of  the  sac,  followed  by 
the  use  of  strong  astringent  injections,  and  aided  by  the  reme- 
dies that  were  directed  to  the  state  of  the  general  health, 
restored  the  antrum  to  a  healthy  condition ;  the  menstrual  dis- 


TREATMENT    OF    ABSCESS.  541 

turbance  was  by  degrees  entirely  cured,  and  the  stomach  at  the 
same  time  assumed  its  healthy  function ;  but  it  was  two  years 
from  the  time  I  first  saw  her  before  she  had  recovered  her 
health,  which  at  the  best  was  never  robust." 

There  is  a  case  described  by  Bordenave,  which,  in  many 
respects,  is  similar  to  the  foregoing ;  but  having  adopted  a  dif- 
ferent treatment,  the  cure  was  more  tardy,  although  ultimately 
effected.  For  the  particulars  of  the  case,  the  reader  is  referred 
to  a  Dissertation  by  the  author  on  the  Diseases  of  the  Maxillary 
Sinus,  page  86. 

Finally,  that  abscess  does  occasionally  form  in  other  parts  of 
the  antrum  than  the  base,  is  conclusively  proven  by  the  cases 
described  by  Bell  and  Bordenave.  It  is  true,  these  are  the  only 
ones  of  which  we  have  any  account,  nevertheless,  they  establish 
the  fact  that  it  is  possible  for  them  to  occur  in  any  part  of  this 
cavity. 


CHAPTER     FIFTH. 

ULCERATION  OF  THE  LINING  MEMBRANE  OF  THE  MAX- 
ILLARY SINUS. 

This  is  not  an  idiopathic  affection.  It  is  always,  we  believe, 
symptomatic  of  some  other  morbid  condition  of  the  mucous  mem- 
brane of  this  cavity,  and  often  gives  rise  to  some  of  the  worst 
and  most  aggravated  forms  of  disease  to  which  it  is  liable.  It 
is  not  a  simple  disease,  but  is  complicated  with  the  one  that 
caused  it,  or  with  some  other  to  which  it  has  given  rise.  We 
shall  treat  of  it,  however,  as  a  separate  affection.  Its  attacks 
are  preceded  by  a  purulent  condition  of  the  fluids  of  the  antrum, 
and  are  often  followed  by  fungus,  and  sometimes  by  caries  of  the 
surrounding  osseous  walls.  The  membrane  covering  the  floor  of 
the  cavity  is  usually  first  attacked ;  ulcers  having  formed  here, 
they  soon  extend  to  other  parts  of  the  sinus. 

Ulcers  of  this  cavity  present  as  great  a  variety  of  character 
as  do  those  of  other  parts  of  the  body.  Their  nature  is  deter- 
mined by  the  state  of  the  constitutional  health  and  the  causes 
that  produce  them.  Without  going  into  a  minute  description  of 
the  various  kinds  of  ulcers,  it  will  be  sufiicient  to  state  that  the 
following  varieties  have  been  met  with  :  namely,  the  simple,  or 
those  resulting  from  mechanical  injury ;  the  fungous,  scorbutic, 
venereal,  cancerous,  gangrenous,  scrofulous ;  the  inveterate,  indo- 
lent, phagedenic,  &c. 

In  the  simpler  species  of  ulcer,  the  discharge  is  of  a  thick 
consistence  and  nearly  white ;  but  as  the  disease  assumes  a 
malignant  type,  it  becomes  thinner  and  varies  in  appearance 
from  a  transparent  to  a  dirty  brown,  yellow  or  black. 

SYMPTOMS. 

Many  of  the  symptoms  attendant  upon  ulceration  of  the 
mucous  membrane  of  the  maxillary  sinus,  are  similar  to  those 


SYMPTOMS    OF    ULCERATION.  543 

that  accompanj  other  aiffections  of  this  cavity ;  as,  for  example, 
deep  seated  heavy  pain  in  the  cheek,  occasional  escape  of  mat- 
ter into  the  nose,  &c.  In  addition  to  constant  pain  in  the  re- 
gion of  the  antrum,  the  following  symptoms  may  be  enumerated — 
the  escape  of  fetid  sanies  either  into  the  nose  on  the  patient's 
inclining  his  head  to  the  opposite  side,  or  through  a  fistulous 
opening,  or  one  that  has  been  formed  by  art  for  its  escape ;  the 
traversing  of  the  ulcer  from  the  interior  through  the  bony  walls 
of  the  cavity  and  external  soft  parts  (an  opening  of  this  sort 
may  be  effected  through  the  cheek,,  near,  or  even  into,  the  orbit, 
or  through  the  canine  fossa  or  palatine  arch) ;  flocculi  mixed 
with  the  matter  escaping  from  the  sinus,  which  is  never  the  case 
in  simple  muco-purulent  secretion  of  the  sinus.  These  flocculi 
sometimes  choke  up  the  natural  opening  of  the  cavity  and  cause 
the  mucous  and  ulcerative  secretions  to  accumulate,  and  distend 
its  osseous  walls  until  they  ultimately  give  way  or  an  opening 
is  formed  for  their  escape.  It  occasionally  happens  that  the 
flocculi  lodged  in  the  nasal  opening  suddenly  give  way,  and 
permit  the  matter  to  pass  into  the  nose. 

When  the  ulcer  is  of  a  fungous  character,  the  matter  secreted 
is  thin,  of  a  dark  brown  or  blackish  color,  and  has  mixed  with 
it  blood  and  pus.*  It  is,  says  Deschamps,  slightly  painful,  and 
can  only  be  distinguished  from  other  ulcers  by  the  introduction 
of  a  bougie  into  the  sinus ;  like  polypus,  it  is  capable  of  spread- 
ing and  penetrating  into  every  opening  that  will  give  it  passage; 
but,  in  consequence  of  its  being  of  a  softer  consistence,  it  makes 
less  impression  upon  the  surrounding  parts. 

If  the  ulcer  be  of  a  cancerous  nature,  the  pain  will  be  sharp 
and  lancinating,  aff"ecting  the  whole  of  the  side  of  the  face: 
the  matter  will  be  serous,  very  fetid,  and  streaked  with  blood. 
If  discharged  through  the  natural  opening  into  the  nose,  it  will 
cause  the  pituitary  membrane  of  the  nasal  cavity  of  the  affected 
side  to  ulcerate,  and  to  become  exceedingly  irritable  and  sensitive 
to  the  touch.  The  bones  of  the  aff"ected  side  of  the  face  become 
softened  or  carious,  the  teeth  loosen,  the  external  soft  parts  in- 
flame and  ultimately  ulcerate ;  openings  are  formed  into  the 
sinu?,  fever  of  a  low  grade  supervenes,  and  a  fatal  issue  is  in- 
evitable. 

*  Maladies  des  Fosses  Nasales,  sec.  2,  art.  vi,  p.  26.3. 


544  CAUSES    OF    ULCERATION. 


CAUSES. 

A  degenerated  or  altered  state  of  the  secretions  of  this  cavity 
is  said  to  be  the  most  common  cause  of  ulceration.  This  may 
be  an  exciting  cause,  and  one  of  the  most  frequent;  but  were  it 
not  favored  by  constitutional  predisposition,  it  would  seldom  give 
rise  to  the  disease.  Local  irritation, — whether  produced  by  an 
altered  condition  of  its  secretions,  or  by  the  presence  of  decayed' 
or  dead  teeth,  the  roots  of  teeth,  or  a  blow  upon  the  cheek, — may 
be,  and  doubtless  is,  an  exciting  cause  of  ulcers  in  the  mucous 
membrane  of  this  cavity.  This,  however,  in  a  subject  of  good 
constitution,  would  have  to  be  very  severe  and  continue  for  a 
long  time,  to  occasion  ulceration,  and  even  then  a  cure  would 
soon  be  effected  by  the  restorative  powers  of  the  economy.  It 
is  only  in  bad  or  debilitated  constitutions  that  malignant  ulcers 
are  met  with  in  the  maxillary  sinus. 

Deschamps,  although  he  acknowledges  that  diseased  teeth 
often  exercise  a  morbid  influence  upon  this  cavity,  and  that  the 
apices  of  the  roots  of  these  organs  are  sometimes  in  contact  with 
its  mucous  or  lining  membrane,  seems  to  doubt  whether  they 
have  any  agency  in  the  production  of  ulcers ;  but  his  reasoning 
upon  the  subject  is  far  from  satisfactory.  While  he  admits  that, 
by  the  contact  and  adhesion  of  the  dental  periosteum  and  mu- 
cous membrane  of  the  antrum,  and  the  penetration  of  its  floor 
by  the  roots  of  teeth,  inflammation  and  ulceration  may  be  pro- 
duced, he  denies  that  it  can  be  positively  proven.  Although  we 
may  not  be  able  to  adduce  positive  evidence,  the  circumstantial 
proofs  are  so  clear  and  strong,  that  no  candid  inquirer  can,  for  a 
single  moment,  doubt  that  the  disease  in  question,  when  favored 
by  a  bad  habit  of  body,  often  results  from  dental  or  alveolar  ir- 
ritation. In  reply  to  the  question  which  he  propounds,  "How 
can  the  extraction  of  a  tooth  be  of  service  in  subduing  inflam- 
mation of  the  mucous  membrane  with  which  the  dental  perios- 
teum is  only  simply  in  contact?"*  we  answer,  by  this  operation, 
a  constant  source  of  irritation  may  be,  and  often  is,  removed. 
Ulcers  having  absolutely  formed,  a  cure  cannot  always  be  eff"ected 
simply  by  the  removal  of  the  exciting  cause. 

*  Maladies  des  Fosses  Nasales,  sec.  2,  art  vi,  p.  259. 


TREATMENT    OF    ULCERATION.  545 


TREATMENT. 


As  in  the  case  of  mucous  engorgement,  the  first  indication  is 
to  give  egress  to  the  purulent  matter;  in  this,  as  in  the  other 
affections,  the  opening  should  be  formed  at  the  most  dependent 
part  of  the  sinus,  and  this  should  be  effected  in  the  manner  be- 
fore described,  through  the  alveolar  border,  or  rather  the  alveo- 
lus of  a  molar  tooth.  It  should  be  made  large  enouirh  to  admit 
the  little  finger,  and  if  there  be  any  teeth  so  much  affected  as 
to  be  productive  of  irritation  to  the  parts  subjacent  to  the  an- 
trum, they  should  be  removed. 

Free  egress  for  the  matter  having  been  obtained,  and  all  local 
irritants  removed,  the  antrum  should  be  injected,  from  time  to 
time,  with  gently  stimulating  and  detersive  fluids.  This,  in 
cases  of  simple  ulcer,  if  the  constitution  is  not  seriously  im- 
paired, "vvill  often  be  all  that  is  required  to  effect  a  cure. 

If  the  ulcer  is  of  a  fungous  nature,  the  employment  of  escha- 
rotics,  and  sometimes  even  the  actual  cautery  becomes  necessary ; 
this  last  should  be  repeated  until  the  fungus  is  completely  de- 
stroyed. With  regard,  however,  to  the  employment  of  escha- 
rotics,  such  as  the  nitrate  of  siver,  sulphate  of  copper,  etc.,  for 
the  purpose  of  destroying  luxuriant  granulations  in  ulcers.  Sir 
E.  Home  is  of  opinion  that  it  is  better  to  combine  them  with 
some  other  substance,  so  as  to  prevent  the  immediate  destruction 
of  the  granulations.  He  believes  that  after  such  destruction, 
the  surface  of  the  ulcer  is  more  liable  to  reproduce  them,  than 
when  they  are  removed  by  absorption;  and  for  this  reason  he 
prefers,  in  the  employment  of  caustics,  to  mix  them  with  other 
substances,  so  that  they  shall  only  exercise  a  strongly  stimulating 
effect,  and  thus  cause  the  granulations  to  be  gradually  removed 
by  the  action  of  the  absorbents. 

The  treatment  of  ulcers  of  this  cavity  is  usually  attended  with 
more  difficulty,  on  account  of  their  concealed  situation,  than 
those  of  most  other  parts  of  the  body.  Among  other  things, 
Deschamps  recommends  injections  of  a  decoction  of  quinine.  In 
many  cases,  a  lotion  of  sulphate  of  zinc  may  be  used  with 
advantage.  The  remedies  to  be  employed  in  the  treatment  of 
ulcers  of  the  maxillary  sinus,  as  in  the  treatment  of  ulcers  of 


546  TREATMENT    OF    ULCERATION. 

other  parts  should  he  varied  to  suit  the  indications  of  each  par- 
ticular case.  In  debilitated  subjects,  tonics,  such  as  quinine  and 
preparations  of  iron,  are  often  serviceable.  There  are  some 
cases  in  which  mercurials  are  beneficial.  Strict  attention  should 
always  be  paid  to  the  regimen  of  the  patient,  and  such  general 
treatment  adopted  as  may  be  best  calculated  to  restore  the 
constitutional  health,  for  upon  this  the  cure  of  the  local  affec- 
tion often  depends. 

If  the  ulcer  is  of  an  irritable  nature,  warm  injections  (thrown 
into  the  antrum  by  means  of  a  properly  constructed  syringe)  of 
decoction  of  poppy  heads,  chamomile  floorers,  or  the  leaves  of 
hemlock,  Avill  often  prove  beneficial  in  soothing  the  pain. 
Tincture  of  myrrh,  diluted,  or  a  decoction  of  walnut  leaves, 
may  be  advantageously  employed  as  injections  in  cases  of  indo- 
lent ulcers ;  the  last  of  these  is  recommended  as  an  application 
to  ulcers  of  this  character,  in  other  parts  of  the  body,  by 
Hunezawsky,  and  both  are  favorably  spoken  of  by  Sir  E.  Home. 
This  last  named  writer  recommends  "  diluted  sulphuric  acid  and 
the  juice  of  the  powder  of  different  species  of  pepper  in  a  recent 
state;"  also  nitrous  acid  diluted  with  water.  The  unguentum 
hydrargyri  nitratis,  mixed  with  lard,  the  ceratum  resinae,  and 
the  unguentum  elemi,  mixed  with  the  balsam  of  turpentine,  are 
also  recommended.  The  application  of  ointment  to  ulcers  of 
this  cavity  can  rarely  be  made. 

Many  of  the  ulcers  of  the  maxillary  sinus  are  regarded  as 
incurable,  as  for  example,  such  as  are  of  a  cancerous  nature  and 
ulcerated  fungus-hematodes.  Although  the  resources  of  surgery 
have  hitherto,  in  most  instances,  proved  inadequate  to  the  cure 
of  these  formidable  diseases,  nevertheless,  they  should  be  put  in 
requisition,  and  ^we  should  endeavor  to  combat  them  by  every 
means  in  our  power.  Deschamps  says,  the  interior  of  the  antrum 
should  be  exposed  at  the  commencement  of  the  disease  He 
recommends  the  formation  of  a  large  opening  above  the  alveolar 
ridge,  if  healthy;  if  not,  through  it,  exposing  as  much  of  the 
cavity  as  possible.  This  done,  he  directs,  if  there  is  a  cancerous 
tumor,  that  it  be  extirpated  as  thoroughly  as  possible  by  means 
of  a  curved  and  flat  bistoury,  or  curved  scissors.  All  that  may 
have  escaped  removal  by  this  means,  he  says,  should  be  touched 
with  the  actual  cautery.     These  are  the  only  remedies  to  be 


TREATMENT    OF    ULCERATION.  547 

employed  Avhen  the  membrane  is  in  a  state  of  cancerous  ulcera- 
tion. The  surgeon  should  destroy  the  parts  in  such  a  way  as  to 
leave  only  the  osseous  surfaces ;  he  should  also  examine  carefully 
these  parts,  and  if  necessary  cauterize  them.  The  disease  having 
been  thus  removed,  the  surrounding  osseous  walls  which  have 
been  cauterized  will  soon  exfoliate;  thus  a  chance  for  a  cure 
will  be  afforded,  of  which,  if  the  neighboring  parts  have  not 
been  too  extensively  involved,  nature  may  avail  herself.  The 
administration  of  soothing  and  anodyne  medicines  are  also 
directed.  Arsenic  has  been  employed  with  advantage  as  an 
external  remedy  in  ulcers  of  this  kind ;  and  modern  surgeons 
use  the  potential  rather  than  the  actual  cautery. 

The  following  case  of  fungous  ulcer,  complicated  with  altera- 
tion of  the  walls  of  the  sinus,  is  taken  from  Bordenave's  collec- 
tion of  observations  on  the  diseases  of  this  cavity,  in  the  Memoirs 
of  the  Royal  Academy  of  Surgery. 

Case  12th.  The  subject  in  this  case  was  a  woman  twenty-six 
years  of  age ;  who  having  exposed  herself,  while  in  a  critical 
state  of  health,  to  cold  air,  was,  in  1759,  attacked  with  acute 
pains  in  the  left  side  of  her  upper  jaw,  in  the  alveolar  ridge  of 
which  were  the  roots  of  several  decayed  teeth.  The  following 
day  her  jaw  was  swollen,  and  although  the  pain  ceased  in  a  few- 
days,  the  swelling  continued,  without  any  change  in  the  appear- 
ance of  the  skin  ;  nevertheless,  her  face  was  deformed  in  shape. 
The  orbital  plate  of  the  maxillary  bone  became  elevated,  and  the 
substance  of  the  bone  softened.  The  interior  of  the  nose  was 
affected,  and  the  opening  of  the  sinus  into  this  cavity  was  closed. 
The  matter  collected  in  the  antrum  began  to  escape,  twenty-two 
days  after  the  attack,  through  the  alveoli. 

In  January,  1761,  the  symptoms  becoming  more  aggravated, 
she  went  to  Paris  for  medical  aid.  M.  Beaupreau  was  consulted, 
and  on  examining  the  affected  parts,  determined  to  extract  the 
decayed  teeth,  Avhich  were  considerably  broken.  They,  however, 
adhered  so  firmly  to  the  alveolar  cavities  that  he  could  not  move 
them  without  shaking  their  sockets.  This  deterred  him  from 
proceeding  with  the  operation  as  he  had  begun,  and  he  resolved 
to  remove  with  a  bistoury,  the  whole  of  the  alveolar  border  from 
the  lateral  incisor  to  the  first  molar,  with  the  teeth  included. 
This  done,  he  made  a  section  of  the  softened  bone  with  a  pair 


548  TREATMENT    OF    ULCERATION. 

of  scissors,  in  the  direction  of  the  cuspid.  The  antrum  was  much 
dilated ;  its  membrane  fungous  and  ulcerated.  He  then  treated 
it  with  detersive  injections,  and  adhesive  dossils,  dipped  in  oil  of 
turpentine.  In  addition  to  these,  mercurial  ointment  and  red  pre- 
cipitate were  used.  Alterative  pills,  and  soothing  beverages 
were  also  prescribed  ;  five  days  after  this  treatment  had  been 
commenced,  the  tumor  had  perceptibly  diminished,  the  pus  be- 
came of  a  better  quality  and  less  in  quantity.  At  the  expiration 
of  two  months,  the  discharge  became  mucous.  Injections  of  lime 
water,  at  first  strong,  and  afterwards  milder,  were  used.  The 
natural  opening  being  closed,  and  continuing  so,  an  opening 
through  the  base  of  the  sinus  was  preserved.  At  the  expiration 
of  two  months,  the  parts  had  recovered,  and  the  general  health 
of  the  patient  was  restored. 

The  medical  treatment  in  the  foregoing  case  was  very  proper  ; 
it  accorded  with  the  curative  indications  of  the  disease;  but  the 
surgical  evidently  involved  a  greater  sacrifice  of  substance  than 
was  absolutely  called  for.  The  extraction  of  teeth  was  not,  how- 
ever, as  well  understood  at  that  time  as  at  present ;  to  the  want 
of  proper  knowledge  and  skill  in  this  department  of  surgery  may 
be  attributed  the  unnecessary  removal  of  so  considerable  a 
portion  of  the  alveolar  ridge.  It  is  often  necessary  to  make 
a  very  large  opening  into  the  sinus,  but  it  is  seldom  requisite  to 
make  one  as  large  as  that  made  in  this  instance  ;  although  nearly 
the  same  treatment  was  adopted  in  a  case  of  a  somewhat  similar 
nature  by  Bourdet.  When  the  subjacent  bone  and  alveolar  bor- 
der are  in  a  carious  or  necrosed  state,  their  removal  would  be 
proper,  and  there  are  diseases  that  occur  in  this  cavity  which 
render  the  operation  necessary;  but  in  neither  of  the  cases  just 
noticed,  were  the  bones  so  carious,  nor  was  the  nature  of  the  dis- 
ease such  as  to  require  so  large  an  opening.  In  the  first  case, 
the  outer  wall  of  the  sinus,  as  would  seem  from  the  description 
given,  was  softened,  but  in  the  other,  Bourdet  says,  the  bones 
were  not  diseased. 

It  sometimes  happens  that  when  the  opening  through  the  alve- 
olar border  is  very  large,  it  never  closes,  and  when  the  natural 
opening  becomes  obliterated,  it  is  requisite  to  preserve  an  artifi- 
cial one  ;  in  either  of  these  cases  the  employment  of  an  artificial 
obturator  is  necessary  to  prevent  particles  of  food  and  extrane- 


TREATMENT    OF    ULCERATION.  549 

ous  matter  from  getting  into  the  sinus.   Of  this  we  shall  hereafter 
speak. 

The  history  of  many  highly  interesting  cases  of  ulceration  of 
the  mucous  membrane  of  this  cavity,  might  be  introduced,  but 
as  this  form  of  diseased  action  is  so  often  complicated  with  caries, 
necrosis,  and  other  alterations  of  its  osseous  walls,  we  have 
thought  it  would  be  as  well  to  reserve  them  until  we  treat  of 
those  afiFections ;  which  we  shall  now  proceed  to  do. 


CHAPTER    SIXTH 


CARIES,  NECROSIS  AND   SOFTENING  OF   THE   BONY 
PARIETES  OF  THE  MAXILLARY  SINUS. 


The  osseous  walls  of  the  antrum,  and  sometimes  the  whole  of 
the  subjacent  alveolar  border,  and  also  the  superior  maxilla, 
the  nasal,  palatine  and  orbital  and  malar  bones,  as  well  as  some 
that  belong  to  the  base  of  the  cranium,  are  involved  in  caries  or 
necrosis.  Mollities  ossium,  though  rarely  occurring  in  the  alve- 
olar ridge,  frequently  affects  the  walls  of  the  sinus.  Caries  may 
affect  a  considerable  portion  of  both  for  a  long  time,  without 
completely  destroying  the  vitality  of  the  diseased  parts.  During 
its  continuance  fetid  sanies  is  discharged  from  one  or  more  fistu- 
lous openings  through  some  part  of  the  cheek,  alveolar  ridge, 
gums,  palatine  arch,  or  into  the  sinus,  and  from  thence  through 
the  natural  opening  into  the  nose.  The  disease  eventually  termi- 
nates in  the  decomposition  and  death  of  the  parts  affected  ;  they 
are  then  separated  from  the  living  bone  and  thrown  off,  in  other 
words,  exfoliated.  Although  caries  ultimately  causes  the  death 
of  the  bone  affected  by  it,  it  does  not  always  precede  the  destruc- 
tion of  vitality.  The  occurrence  of  necrosis,  therefore,  although 
it  may  result  as  a  consequence  of  caries,  is  not  necessarily  de- 
pendent upon  it. 

When  the  parietes  of  the  antrum  or  alveoli  are  affected  by  ne- 
crosis, the  soft  parts  in  contact  with  the  diseased  or  dead  bone, 
inflame,  ulcerate  and  discharge  fetid  ichorous  matter.  The  gums 
sometimes  become  fjangrenous  and  slouith.  The  destruction  of 
the  vitality  of  the  osseous  parts  often  progresses  very  slowly, 
and  thus,  piece  after  piece  is  exfoliated,  until  the  disease  is 
arrested. 

Besides  these  affections,  it  not  unfrequently  happens  that  the 
osseous  parietes  of  this  cavity  are  so  softened  as  to  be  easily 
bent.     This   alteration  of  the  bone,  as  well  as   the  others  just 


SYxMPTOMS    OF    CARIES    AND    NECROSIS.  551 

noticed,  are,  in  nearly  every  instance,  preceded  by  some  other 
form  of  disease. 

The  annoyance  to  the  patient,  occasioned  by  caries  and  necro- 
sis of  the  bony  walls  of  this  cavity  or  of  the  alveoli,  is  very 
great.  The  fetor  of  the  sanies  is  sometimes  almost  insufferable ; 
the  matter  often  excoriates  and  inflames  the  parts  with  which  it 
comes  in  contact,  to  such  a  degree,  as  to  cause  them  to  become 
exceedingly  sensitive  and  not  unfrequently  to  ulcerate. 

SYMPTOMS. 

It  is  sometimes  difficult  to  distinguish  caries  and  necrosis  of 
the  bony  parietes  of  the  antrum  from  some  of  the  other  diseases 
of  this  cavity.  They,  therefore,  often  exist  for  a  long  time 
without  being  suspected.  The  signs  that  indicate  mollities 
ossium,  or  softening  of  the  walls,  are  such  as  not  to  be  easily 
mistaken  for  those  of  any  other  affection.  In  this  disease,  the 
walls  of  the  sinus  yield  to  pressure,  and  regain  their  former 
shape  when  the  pressure  is  removed.  Its  existence,  therefore, 
may  always  be  known  by  this  sign,  and  as  this  is  sufficient,  it  is 
not  necessary  to  enumerate  any  others  by  which  it  is  character- 
ized. Caries  and  necrosis  not  being  so  easily  detected,  often 
make  considerable  progress  before  their  existence  is  ascertained. 
The  fetor  and  appearance  of  the  matter  discharged  do  not  always 
furnish  a  diagnosis  that  can  be  relied  upon,  inasmuch  as  some  of 
the  diseases  that  occur  here  are  marked  by  secretions  equally  as 
offensive  as  the  sanies  resulting  from  caries  or  necrosis,  and  not 
unlike  it  in  appearance.  Their  existence  may,  in  most  instances, 
be  inferred,  from  the  discharge  of  dark  colored  fetid  sanies. 
The  exfoliation  of  pieces  of  bone  will  set  all  doubt  at  rest. 

Caries  or  necrosis  may  often  be  detected  by  perforating  the 
antrum  and  exposing  the  denuded  or  diseased  bone ;  or  when 
there  is  an  external  opening,  by  probing  it.  In  this  way  any 
loose  or  dead  bone  may  be  felt  with  the  instrument,  and  the 
diagnosis  in  either  case  will  be  satisfactory. 

When  caries  or  necrosis  is  situated  in  the  alveolar  border  or 
floor  of  the  antrum,  its  existence  can  be  more  readily  ascertained. 
The  occurrence  of  either  in  the  alveolar  ridge,  causes  the  gums 
to  inflame;  to  assume  a  dark  purple  or  livid  appearance;  to 


552  CAUSES    OF    CARIES    AND    NECROSIS. 

separate  from  the  sockets  of  the  teeth,  and  frequently  to  slough 
in  large  pieces  and  expose  the  caried  or  necrosed  bone.  When 
situated  in  the  floor  of  the  antrum,  the  rough  denuded  bone  may- 
be easily  felt  with  a  probe  or  stilet,  introduced  through  the 
fistula  of  the  gums  or  the  alveolus,  through  which  the  mutter  is 
discharged. 

The  pain  accompanying  these  affections  does  not  constitute  a 
diagnosis  of  much  importance,  since  this  is  common  to  several 
other  diseases. 

CAUSES. 

The  immediate  cause  of  caries  and  necrosis  of  the  osseous  walls 
of  the  antrum  maxillare  is  suppurative  inflammation,  or  the  de- 
struction of  their  periosteum  ;  these  may  result  from  a  purulent 
condition  of  the  secretions  of  the  mucous  membrane,  engorge- 
ment, tumors,  a  blow  upon  the  cheek,  or  from  other  kinds  of 
mechanical  violence ;  they  may  also  arise  from  the  in-itation 
produced  by  diseased  teeth.  Fouchard  says  he  saw,  in  the 
Anatomical  Museum  of  the  University  of  Copenhagen,  a  prepa- 
ration in  which  there  had  been  caries  of  the  bones  of  the  face, 
produced  by  a  molar  tooth,  the  crown  of  which,  having  turned 
outward,  had  penetrated  the  maxillary  sinus.  The  pressure  of 
incarcerated  fluids  may,  perhaps,  be  regarded  as  the  most  fre- 
quent cause ;  and  from  this,  too,  result  some  of  the  most  aggra- 
vated forms  of  disease  that  ever  attack  this  cavity. 

A  morbid  action  kept  up  in  the  periosteum  for  a  long  time, 
by  ulceration  of  the  lining  membrane,  or  any  other  aggravated 
form  of  disease  in  the  sinus  or  neighboring  soft  parts,  is  apt  to 
give  rise  to  caries  of  the  bone;  but  when  the  inflammation  is  so 
severe  as  to  cause  the  immediate  destruction  of  the  periosteal 
tissue,  necrosis  at  once  takes  place. 

Softening  of  the  bone  seems  to  result  from  some  alteration  in 
the  progress  of  growth  or  development;  in  consequence  of  which, 
the  normal  proportion  between  the  animal  and  mineral  constitu- 
ents of  the  bone  are  changed.  Inflammation  and  ulceration  of 
the  mucous  membrane  is  its  almost  invariable  attendant  when  it 
occurs  in  the  walls  of  the  antrum.  What  this  altered  state  is, 
and  why  it  should  be  so  purely  local  as  in  some  of  these  cases, 
are  questions  not  easily  answered. 


TREATMENT    OF   CARIES    AND    NECROSIS.  553 


TREATMENT. 

Complicated,  as  caries,  necrosis  and  other  diseases  of  the  os- 
seous walls  of  the  maxillary  sinus  most  frequently  are,  with 
other  affections  of  this  cavity,  their  cure  is  often  difficult  and 
generally  tedious.  The  first  indication  to  be  fulfilled,  however, 
in  their  treatment,  as  in  the  case  of  engorgement,  and  of  a 
muco-purulent  condition  of  the  secretions,  is  to  obtain  free  egress 
for  any  fluids  which  may  have  accumulated  here.  This  may  be 
effected  in  the  manner  before  described.  If,  in  addition  to  this, 
the  disease  of  the  osseous  tissue  is  complicated  with  any  other 
affection  of  the  sinus,  such  means  as  are  necessary  for  the  cure 
of  that  affection  should  at  once  be  employed;  but  it  is  not  ne- 
cessary here  to  describe  the  treatment  of  the  complicating  dis- 
eases, as  that  has  already  or  will  hereafter  be  done. 

Deschamps,  in  treating  upon  the  osseous  diseases,  recommends 
the  employment  of  detersive  and  stimulating  injections,  a  de- 
coction of  quinine,  tincture  of  myrrh  and  aloes,  &c.  These  last, 
he  says,  may  be  introduced  as  injections,  or  by  means  of  pledgets 
moistened  with  them.  He  also  directs  the  cavity  to  be  "  cleared 
of  all  foreign  matter  which  may  have  obtained  admission  into 
it."  This  treatment,  having  a  tendency  to  promote  a  healthy 
action  in  the  lining  membrane,  will  often  be  all  that  is  required. 
It  should  be  continued  until  the  caried  or  necrosed  bone  has  ex- 
foliated, and  the  secretions  of  the  antrum  cease  to  exhale  an 
offensive  odor.  The  dead  bone  having  exfoliated,  a  cure  is  gen- 
erally soon  effected. 

It  sometimes  happens  that  the  disease  of  the  bone  has  been 
produced  by  some  very  malignant  and  incurable  affection  of  the 
soft  parts.  In  this  case,  the  resources  of  art  will,  of  course, 
prove  unavailing.  When  the  disease  of  the  bone  has  extended 
itself  to  the  greater  part  of  the  superior  maxilla  and  the  bones 
with  which  it  is  connected, — the  nasal,  palate,  ethmoid,  &c. — 
the  most  that  can  be  hoped  for,  from  the  skill  of  the  physician, 
is  a  palliation  of  the  symptoms.  Art,  in  such  cases,  can  seldom 
effect  a  cure ;  whilst  there  are  others  in  which  it  can  only  retard 
the  progress  of  the  disease,  or  assist  nature  in  her  efforts  to  sepa- 
rate the  dead  from  the  living  bone. 
36 


554  TREATMENT    OF    CARIES    AND   NECROSIS. 

It  is  impossible  to  lay  down  rules  for  the  treatment  of  disease 
in  the  walls  of  the  maxillary  sinus,  from  which  it  will  not  be 
necessary  occasionally  to  deviate.  It  will  be  sufiBcient  to  state, 
that  where  they  are  extensively  involved  in  caries  or  necrosis, 
it  will  be  proper,  in  addition  to  perforating  the  base  of  the 
sinus,  if  by  this  means  the  dead  bone  cannot  be  so  exposed 
as  to  enable  the  surgeon  to  detach  it  from  the  living,  to  cut 
away  the  whole  of  the  alveolar  border  beneath  the  cavity, 
or  to  penetrate  the  sinus  above  it,  or  even,  as  Deschamps  recom- 
mends, "  through  the  cheek  itself,  whether  there  be  a  fistula 
penetrating  those  parts  or  not."  Having,  by  this  means,  ex- 
posed the  necrosed  bone,  it  should  be  carefully  detached  from 
the  sound,  and  removed. 

The  character  which  the  affections  of  this  cavity  put  on, 
being  determined  by  the  state  of  the  constitution  or  some  par- 
ticular vice  of  body,  it  often  becomes  necessary  in  their  treat- 
ment, to  have  recourse  to  general  remedies.  If  the  subject  is 
of  a  scrofulous  or  scorbutic  habit,  or  is  affected  wath  any  specific 
constitutional  vice,  such  remedies  as  are  indicated  by  this  affec- 
tion of  the  general  system  should  be  employed.  Although  the 
character  and  malignancy  of  the  disease  are  thus  determined, 
its  occurrence  seems  to  be  dependent  upon  local  irritation.  Its 
continuance,  in  many  instances,  results  from  this ;  and  the  cure, 
in  such  cases,  soon  follows  the  removal  of  the  cause  that  gave 
rise  to  it,  as  in  the  following  case  : 

Case   13th.  L.   S ,  a  maiden  lady  about  thirty  years  of 

age,  of  a  scorbutic  habit,  had  been  affected  with  pain  in  her  left 
cheek  and  alveolar  ridge  for  nearly  two  years,  which  at  times 
was  almost  insupportable.  Nearly  all  her  teeth  were  affected 
with  caries ;  from  around  the  necks  of  several,  on  the  left  side 
in  the  superior  maxilla,  fetid  sanies  had  been  exuding  for  two 
or  three  months,  and  her  appetite  had  become  greatly  impaired. 
A  tumor  half  the  size  of  a  black  walnut,  having  formed  upon  the 
palatine  arch  of  the  affected  side,  she  became  alarmed,  and  in 
the  fall  of  1840,  came  to  Baltimore  for  medical  aid.  She  ap- 
plied to  Professor  T.  E.  Bond,  who,  after  investigating  the  case, 
and  satisfying  himself  that  the  affection  was  the  result  of  the 
diseased  condition  of  her  teeth,  advised  her  to  place  herself  under 
our  care,  which  she  did  on  the  following  day. 

The  sockets  of  four  of  the  teeth  of  the  affected  side,  in  the 


TREATMENT    OF    CARIES    AND   NECROSIS.  555 

superior  maxilla,  were,  on  examination,  found  to  be  in  a  necrosed 
condition,  as  was  also  a  part  of  the  palate  bone  of  the  same  side. 
The  gums  around  these  teeth  had  separated  from  the  alveolar 
process,  and  had  a  dark,  livid  appearance.  A  thin,  dark-colored, 
ichorous  matter,  which,  when  brought  in  contact  with  silver,  al- 
most instantly  turned  it  black,  was  constantly  exuding  from  be- 
tween the  gum  and  the  necks  of  the  teeth.  The  left  nostril  was 
dry,  and  the  opening  from  the  sinus  had  evidently  closed.  Ex- 
ceedingly fetid  matter  had  been  discharged  from  it  during  the 
early  stages  of  the  disease.  The  tumor  on  the  left  side  of  the 
arch  of  the  palate  was  soft  and  elastic.  When  pressed,  dark- 
colored  sanies  was  discharged  from  the  alveoli,  and  then,  for  a 
time,  ceased. 

The  alveolar  processes  being  in  a  necrosed  and  loose  condi- 
tion, it  was  with  some  difficulty  we  succeeded  in  removing  the 
bicuspids  and  the  first  and  second  superior  molars  of  the  left 
side,  without  bringing  their  sockets  with  them.  The  operation 
was  followed  by  a  discharge  of  a  considerable  quantity  of  fetid 
sanies ;  and,  in  a  few  days,  the  alveoli  having  become  completely 
detached  from  the  sound  bone,  we  removed  them,  together  with 
a  part  of  the  floor  of  the  antrum.  The  opening  thus  formed  into 
the  sinus  was  large  enough  to  admit  the  end  of  the  forefinger. 
Several  small  pieces  of  bone  were  afterwards  exfoliated  from 
where  the  teeth  had  been  extracted,  and  three  pieces  from  the 
left  side  of  the  arch  of  the  palate. 

Without  any  other  treatment,  the  place  from  which  the  teeth 
and  alveoli  had  been  removed  had,  in  about  seven  weeks,  become 
entirely  covered  with  firm  and  healthy  granulations,  except  the 
opening  that  communicated  with  the  maxillary  sinus.  From  the 
opening  into  the  antrum,  fetid  matter  was  still  discharged.  This 
became  less  and  less  offensive,  until,  at  the  expiration  of  six  or 
eight  weeks,  the  opening  into  the  nose  having  become  re-estab- 
lished, it  lost  its  fetid  odor,  and  the  aperture  at  the  base  of  the 
sinus  soon  after  closed.  Thus,  in  a  little  more  than  three  months, 
a  complete  cure  was  effected.  The  patient  left  the  city  in  the 
following  spring,  and  we  have  not  since  heard  from  her. 

The  following  case  is  abridged  from  Bordenave's  Observations 
on  the  Diseases  of  the  Antrum  Maxillare,  as  published  in  the 
Memoirs  of  the  Royal  Academy  of  Surgery. 

Case  14th.    A  man,  whose    right  superior  maxilla,  at  the 


656  TREATMENT    OF    CARIES   AND   NECROSIS. 

upper  part,  had  been  swollen  for  about  three  months,  had,  at  the 
same  time,  a  soft  tumor  on  the  anterior  of  the  palate,  which,  on 
being  pressed,  caused  matter  to  be  discharged  from  the  nostril 
of  that  side.  These  affections,  together  with  tumefaction  of  the 
gums,  looseness  of  several  of  the  teeth,  and  fetid  breath,  induced 
M.  Planque,  under  whose  care  the  patient  was  placed,  to  suspect 
suppuration  of  the  maxillary  sinus,  complicated  with  a  scorbutic 
diathesis  of  the  general  system.  The  molars,  which  only  adhered 
to  the  gums,  having  been  extracted,  matter  was  discharged 
through  their  alveoli.  A  portion  of  the  maxillary  bone  was  now 
discovered  to  be  carious,  and  this,  in  about  a  month,  began  to 
loosen,  and  after  some  time,  a  piece  of  about  an  inch  and  a  half 
long,  and  half  an  inch  in  width,  exfoliated.  The  external  tumor 
disappeared ;  the  walls  of  the  sinus  approximated,  and  a  cicatrix 
ultimately  closed  the  opening. 

The  details  of  many  similar  cases  are  on  record,  but  it  would 
be  extending  the  limits  of  this  part  of  the  work  too  far  to  intro- 
duce them  here.  The  history  of  the  cases  already  given  will 
suffice  to  illustrate  the  treatment  of  these  affections.  We  would, 
however,  have  given  a  case  of  moUities  ossium  of  the  walls  of 
this  cavity,  had  we  not,  while  treating  of  ulceration  of  the  lining 
membrane,  quoted  one  in  which  it  had  become  complicated  with 
this  affection. 

It  sometimes  happens,  when  a  very  large  opening  has  been 
formed  through  the  inferior  part  of  this  cavity,  that  it  does  not 
always  readily  close.  It  is  true  that  this  does  not  often  occur, 
unless  the  natural  opening  has  become  obliterated.  When  the 
parts  do  not  manifest  a  disposition  to  unite,  the  practice  intro- 
duced by  Bordenave  and  Scultet,  which  consists  in  cauterizing 
the  interior  circumference  of  the  opening,  will,  in  most  instances, 
prove  successful.  If  this  and  all  other  means  fail,  the  opening 
may  be  closed  by  means  of  an  obturator  of  fine  gold.  This 
should  be  accurately  fitted  to  the  parts,  and  secured,  by  means 
of  a  broad  clasp,  to  a  molar  or  bicuspid  tooth,  and  if  there  be 
none  suitable  on  this  side  of  the  mouth,  to  which  it  can  be 
applied,  the  gold  should  be  extended  to  one  on  the  opposite  side. 
If  it  be  necessary  to  replace  the  lost  teeth  with  artificial  ones, 
these  may  be  so  mounted  that  the  plate  upon  which  they  are  set 
shall  cover  the  opening  into  the  maxillary  sinus,  and  thus  obviate 
the  necessity  of  any  other  obturator. 


CHAPTER    SEVENTH. 

TUMORS  OF  THE  LINING  MEMBRANE  AND  PERIOSTEUM 
OF  THE  MAXILLARY  SINUS. 

The  lining  membrane  and  periosteum  of  the  maxillary  sinus 
occasionally  become  the  seat  of  fungous  and  other  tumors,  and 
in  consequence  of  the  concealed  situation  of  the  cavity,  morbid 
growths  originating  in  it  often  make  considerable  progress  be- 
fore they  attract  attention  ;  hence,  the  efforts  of  art  for  their 
cure,  which  might  otherwise  frequently  be  successful,  in  most 
instances  prove  unavailing.  The  presence  of  a  tumor  may  give 
rise  to  all  the  diseases  to  which  its  osseous  walls  are  liable,  as 
well  as  to  most  of  those  incident  to  its  soft  tissues.  As  soon  as 
the  morbid  growth  has  filled  the  sinus,  it  presses  upon  the  lining 
membrane,  excites  inflammation,  and  sometimes  ulceration,  caus- 
ing its  secretions  to  become  vitiated.  A  diseased  action  is  com- 
municated to  the  periosteum  of  the  surrounding  osseous  walls, 
this  ceases  to  furnish  the  hard  tissues,  with  the  healthy  juices 
which  they  require  for  their  preservation ;  the  periosteum  thickens, 
ulcerates,  and  is  destroyed,  or  exudes  a  corrosive  fluid.  The 
bony  parietes  are  softened  or  become  affected  with  caries  or  ne- 
crosis, and  one  or  more  fistulous  openings  are  formed  through 
the  cheek,  alveoli,  or  palatine  arch. 

These  are  not  the  only  effects  that  result  from  tumors  situated 
in  this  cavity.  As  they  increase  in  volume,  after  having  filled 
the  antrum,  they  gradually  distend  and  displace  its  bony  walls  ; 
the  floor  of  the  orbit  is  sometimes  elevated,  and  the  eye  more  or 
less  forced  from  its  socket ;  the  palatine  arch  and  alveolar  ridge 
are  depressed,  and  the  teeth  loosen  and  drop  out.  When  the 
tumor  is  of  a  soft  fungous  nature,  it  i?^t  unfrequently  escapes 
through  the  alveoli  into  the  mouth,  and  after  forcing  the  jaws 
asunder  to  their  greatest  extent,  protrudes  from  it  in  enormous 
masses.  Bertrandi  gives  the  history  of  a  case  of  polypus  ex- 
crescence  of   the   antrum,    which,    after   having   destroyed   the 


558  TUMORS  OF  THE  ANTRUM. 

palate,  anterior  part  of  the  maxillary  bone,  and  filled  the  mouth, 
forced  itself  up  into  the  orbit,  elevated  its  roof,  pressed  upon  the 
brain,  and  ultimately  occasioned  apoplexy  and  death.  Other 
similar  cases  are  on  record.  Mr.  Cooper  says  there  are  three 
specimens  of  diseased  antrum  in  the  museum  of  the  London  Uni- 
versity College.  The  tumor  in  two  of  these  had  "  made  its  Avay 
from  the  antrum  to  the  brain."  The  third  was  taken  from  a 
patient  of  his,  which  had  died.  The  tumor  in  this  case,  which 
was  of  a  medullary  and  scirrhous  character,  forced  itself  up  into 
the  orbit,  displaced  the  eye,  and,  ultimately,  caused  the  death  of 
the  patient.  The  same  author  mentions  another  case  ;  the  sub- 
ject was  a  boy  in  St.  Bartholomew's  Hospital,  who  had  a  tumor 
of  the  antrum,  which  ''  made  its  way  through  the  orbital  plate 
of  the  frontal  bone  and  cribriform  plate  of  the  ethmoid  into  the 
cranium,"  and  though  the  portion  of  it  that  entered  the  brain 
was  as  large  as  a  small  orange,  he  says  the  boy  was  in  a  coma- 
tose state  only  about  forty-eight  hours  previously  to  his  death. 

Tumors  occupying  the  maxillary  sinus  do  not  always  originate 
in  the  lining  membrane  or  periosteum.  They  sometimes  arise 
from  the  pituitary  membrane  of  the  nose,  frontal  sinus,  or  eth- 
moidal cells,  and  after  having  found  their  way  into  this  cavity, 
augment  in  size,  until  they  produce  the  effects  just  described. 
Some  suppose  that  the  morbid  productions  found  here,  originate 
more  frequently  in  the  cells  of  the  ethmoid  bone,  than  in  the 
lining  membrane  of  this  cavity. 

We  are  disposed  to  believe  that  this  opinion  is  not  well 
founded,  and  that  it  has  chiefly  resulted  from  the  great  liability 
of  most  kinds  of  tumors  of  this  cavity,  to  be  reproduced  after 
having  been  extirpated — which  is  attributable  to  the  continuance 
of  the  cause  that  gave  rise  to  them  in  the  first  instance,  or  to 
their  imperfect  removal.  That  they  do,  however,  sometimes 
originate  in  the  ethmoidal  cells,  there  can  be  no  question. 

It  sometimes  happens  that  tumors  having  their  seat  in  the 
antrum,  after  having  filled  it,  make  their  way  into  the  nose, 
where  they  acquire  a  size  equal  to,  or  even  greater,  than  that 
which  they  had  previously  obtained,  thus  dividing  themselves,  as 
it  were,  into  two  parts — one  occupying  the  antrum,  and  the 
other  one  of  the  nasal  cavities.  Occurrences  of  this  sort  are 
not  unfrequent,  and  they  sometimes  mislead  as  to  the  real  seat 


TUMORS    OF    THE    ANTRUM.  559 

of  the  disease.  Thus,  a  polypus  of  the  antrum  is  occasionally 
mistaken  for  one  of  the  nose,  and  the  error  frequently  not  dis- 
covered until  an  attempt  is  made  to  remove  it. 

The  character  of  morbid  growths,  in  this  cavity,  is  exceed- 
ingly variable,  according  to  the  causes  that  give  rise  to  them  and 
the  state  of  the  constitutional  health  of  different  individuals. 
They  not  only  vary  in  their  appearance  and  structure,  but  in 
their  degree  of  malignancy.  Some  are  of  a  healthy  flesh-color, 
soft,  sensitive,  but  not  painful,  and  present  a  smooth,  regular 
surface;  others  varying  in  their  consistence  from  hard  to  soft, 
and  in  their  color  from  pale  yellow  to  deep  red  or  purple,  pre- 
senting a  rough,  irregular,  and  not  unfrequently  ulcerated  sur- 
face, and  are  more  or  less  sensitive  to  the  touch.  Some  have 
their  origin  in  the  mucous  membrane;  others,  both  in  this  and 
the  periosteum.  Some  are  attached  by  a  broad  base;  others, 
only  by  a  mere  peduncle. 

As  it  regards  this  latter  description  of  tumors,  which  are 
usually  designated  by  the  name  of  polypi,  their  occurrence  in 
the  maxillary  sinus  is  questioned  by  some  writers.  Sir  Benja- 
min Brodie  does  not  believe  they  are  ever  found  in  this  cavity  ;* 
and  in  this  opinion  Mr.  S.  Cooper  fully  concurs ;  yet  that  they 
are  occasionally  met  with,  seems  to  be  conclusively  established.  A 
case  described  by  M.  Bertrandi  in  his  treatise  on  Operative  Surgery, 
page  369,  has  already  been  referred  to;  and  Bordenave,  in  his 
Observations  on  the  Diseases  of  the  Antrum  Maxillare,  gives 
the  history  of  a  case  treated  by  M.  Doublet.  Rusch  declares 
that  he  has  twice  seen  polypus  of  this  cavity,  and  Pettit,  Lev- 
rette,  and  other  writers  also  affirm  that  they  have  found  polypi 
here.t  It  must  be  admitted,  then,  that  polypi  in  the  maxillary 
sinus,  although  very  rare,  do  sometimes  occur :  although  other 
descriptions  of  tumors  are  more  frequently  met  with  in  this  cavity. 
Of  these,  some  are  of  a  simple  fibrous,  sarcomatous,  or  osteo- 
sarcomatous  nature, |  and  when  thoroughly  extirpated,  are  sel- 
dom reproduced;  others  are  of  a  medullary  or  carcinomatous 
character.    These  last,  although  originating  in  the  mucous  raem- 

*  London  Medical  Gazette,  for  December,  1834,  p.  850. 

t  Traite  des  Maladies  de  la  Bouche,  torn.  1,  p.  212,  and  Polypes  de  la  Matricc,  de  la 
Gorge,  et  du  Nez,  p.  253. 

t  Professor  Reese's  Appendix  to  Cooper's  Surgical  Dictionary,  American  edition, 
1842. 


560  SYMPTOMS    OF    TUMORS,    ETC. 

brane,  are  very  liable  to  be  reproduced  after  their  removal,  and 
generally  occasion  the  death  of  the  patient. 

It  sometimes  happens  that  several  fungous  tumors  spring  up 
from  opposite  points.  The  chances  of  cure,  when  this  is  the 
case,  especially  if  they  are  of  a  malignant  character,  are  greatly 
lessened. 

Tumors  of  this  cavity  seldom  grow  very  fast  during  the  early 
stages  of  their  formation ;  but,  as  they  enlarge,  the  neighboring 
parts  become  involved  in  the  diseased  action,  and  they  assume  a 
character  of  greater  malignancy  and  increase  more  rapidly  in 
size. 


SYMPTOMS. 

The  occurrence  of  tumors  in  the  maxillary  sinus  is  rarely  ac- 
companied by  symptoms  diflfering  materially  from  those  occa- 
sioned by  many  of  the  other  affections  that  locate  themselves 
here,  previously  to  their  having  obtained  a  size  sufficiently  large 
to  fill  it.  After  they  have  filled  the  sinus,  the  indications  soon 
become  less  equivocal.  Swelling  of  the  cheek,  depression  of  the 
palatine  arch  and  alveolar  ridge,  loosening  of  the  superior  molar 
teeth  of  the  affected  side,  inflammation  and  sponginess  of  the 
gums,  elevation  of  the  floor  of  the  orbit,  and  protrusion  or  con- 
cealment of  the  eye,  are  symptoms  which  result  from  the  presence 
of  tumors  in  this  cavity ;  but  they  are  not  peculiar  to  these 
affections,  as  many  of  them  are  produced  by  mucous  engorge- 
ment of  the  sinus.  When  to  these  is  superadded  the  discharge 
of  bloody  sanies  from  the  nose,  or  from  one  or  more  fistulous 
openings  through  the  check,  alveolar  ridge,  or  palatine  arch, 
the  diagnosis  will  be  conclusive,  and  the  existence  of  a  tumor  in 
the  antrum  established  beyond  doubt. 

There  are  also  other  signs  by  which  the  occurrence  of  a  morbid 
growth  in  this  cavity  may  be  known  ;  as,  for  example,  dropping 
out  of  the  superior  molars  of  the  affected  side,  and  the  protrusion 
of  portions  of  the  tumor  through  the  alveoli. 

The  pain  is  seldom  severe  until  the  tumor  has  filled  the  cavity, 
unless  the  excresence  is,  from  the  first,  of  a  malignant  character ; 
as  it  augments  in  size  and  forces  the  walls  of  the  sinus  asunder, 
it  becomes  more  and  more  severe.     Sometimes,  during  the  pro- 


TREATMENT    OF    TUMORS,    ETC.  5t>l 

gress  of  the  disease,  it  becomes  most  excruciating.  In  a  case 
of  fungus-hematodes  of  tiiis  cavity,  which  the  author  had  an 
opportunity  of  witnessing  in  1835,  the  patient  was  in  the  habit 
of  taking  upwards  of  two  tea-spoonfuls  of  black  drop  at  a  time, 
for  the  procurement  of  ease  and  sleep. 

In  addition  to  the  foregoing  symptoms,  several  of  the  affections 
already  described,  together  with  their  attendant  symptoms,  not 
unfrequently  result  from  tumors  in  this  cavity.  Inflammation 
and  ulceration  of  its  lining  membrane,  a  purulent  condition  of 
its  secretions,  caries,  necrosis,  and  softening  of  its  osseous  walls, 
seldom  fail  to  attend  some  of  the  stages  of  the  formation  of  the 
morbid  productions  under  consideration.  It  is  unnecessary  to 
mention  the  symptoms  peculiar  to  each  variety  of  tumor,  as 
they  are  given  by  writers  on  general  surgery. 

CAUSES. 

Most  writers  on  the  affections  of  the  maxillary  sinus,  are  of 
opinion  that  tumors  in  this  cavity  result  spontaneously,  as  a 
consequence  of  some  specific  constitutional  vice,  independently 
of  local  causes.  We  do  not  believe  that  they  are  ever  developed 
spontaneously.  That  a  bad  habit  of  body,  or  some  constitutional 
vice  is  necessary  to  their  production,  is  very  probable ;  but  that 
this  is  capable  of  giving  rise  to  them  in  parts  uninfluenced  by 
local  irritation,  we  think  exceedingly  questionable.  Having, 
however,  already  expressed  our  views  with  regard  to  the  agency 
of  particular  habits  of  body  and  constitutional  vices  in  the  pro- 
duction of  disease  in  this  cavity,  it  will  not  be  necessary  to 
repeat  what  we  have  before  said  upon  the  subject.  It  will  be 
sufficient  to  remark  that  most,  if  not  all  of  the  morbid  excres- 
cences met  with,  result  from  local  irritation,  favored  by  constitu- 
tional vices ;  and  that  both  are  necessary  to  their  production. 

TREATMENT. 

It  is  only  in  the  earlier  stages  of  the  formation  of  tumors  in 
this  cavity,  that  surgical  treatment  can  be  adopted  with  success, 
and  even  then,  their  entire  extirpation  is  absolutely  essential, 
otherwise  a  speedy  return  of  the  disease  is  certain.     But,  pre- 


562  TREATMENT    OF   TUMORS,    ETC. 

paratory  to  the  removal  of  the  diseased  structure,  a  large  open- 
ing should  be  made  into  the  antrum,  so  as  to  expose  as  much  of 
it  as  possible.  Deschamps  recommends  as  the  most  proper  place 
for  effecting  this,  when  the  alveolar  ridge  has  been  started,  the 
removal  of  the  first  or  second  molar,  and  the  perforation  of  the 
sinus  through  its  socket  with  a  "  three-sided  trocar  of  suitable 
dimensions."  When  the  alveolar  ridge  and  teeth  are  sound,  he 
directs  the  opening  to  be  made  through  the  outer  wall  of  the 
sinus  above  the  ridge,  and  this,  he  thinks,  on  account  of  its  being 
more  direct,  is  preferable  to  the  other  mode.  An  opening  may 
be  easily  effected  in  either  way  into  the  sinus,  as  its  walls  are 
generally  so  much  softened  as  to  offer  but  little  resistance. 

When  the  opening  is  made  through  the  external  parietes,  the 
instrument  recommended  by  Mr.  Thomas  Bell,  for  cutting  away 
the  bone  after  it  has  been  exposed,  is  a  "strong  hooked  knife," 
which  is  probably  as  well  adapted  to  the  purpose  as  any  that  can 
be  used.  Some  surgeons  employ  strong  curved  scissors,  but  the 
hooked  knife  we  think  preferable. 

A  free  opening  having  been  effected,  a  finger  of  the  operator 
should  be  introduced,  and  the  nature  of  the  diseased  structure 
ascertained.  This  done,  he  will  be  able  to  determine  what 
course  to  pursue  for  its  removal.  If  the  tumor  partakes  of  the 
character  of  polypus,  it  may  be  seized  with  a  pair  of  forceps,  and 
torn  away ;  if  it  be  attached  by  a  broad  base,  its  extirpation  will 
be  most  readily  effected  with  a  knife.  But  even  with  this,  it 
is  often  exceedingly  difficult  to  effect  its  total  removal;  so  that 
it  not  unfrequently  becomes  necessary  to  employ  the  actual  or 
potential  cautery;  for,  if  any  small  portions  be  left  behind,  as 
has  before  been  stated,  a  reproduction  of  the  disease  will  gene- 
rally very  soon  take  place.  When  the  disease  has  originated,  or 
is  seated  in  the  periosteum,  the  actual  cautery  has  proved  to  be 
the  most  effectual  means  of  preventing  its  return.  French  sur- 
geons have  applied  it  with  great  success.  Desault,  in  a  case  of 
fungous  tumor,  succeeded  in  effecting  a  cure,  after  three  appli- 
cations. The  root  of  the  disease  can  often  be  destroyed  by  the 
employment  of  this,  when  less  effectual  means  would  fail.  But 
it  is  important,  when  it  is  had  recourse  to,  that  it  should  have 
such  a  degree  of  heat  as  to  accomplish  the  object  instantanously, 
else  the  inflammation  that  would  otherwise  be  excited  in  the 


TREATMENT    OF    TUMORS,    ETC.  563 

surrounding  parts,  by  its  application,  would  greatly  retard,  if  it 
did  not  prevent,  the  cure.  Mr.  Thomas  Bell  says,  "the  Avhite 
heat  should  be  employed." 

In  remarking  upon  the  bold  practice  of  the  French  surgeons 
in  the  treatment  of  these  afifections,  the  author  just  quoted 
remarks:  "It  is  worthy  of  our  praise  and  imitation;  the  timidity 
which,  until  very  lately,  almost  excluded  the  use  of  the  actual 
cautery  in  this  country,  has  been  one  cause,  and  that  a  very 
prevalent  one,  of  failure  in  the  treatment  of  some  of-  these 
cases ;  but  it  is  not  so  easy  to  account  for  the  still  more  culpable 
dread,  which  has,  in  so  many  instances,  prevented  any  attempt 
being  made  to  extirpate  the  disease;  a  degree  of  pusillanimity, 
which  is  at  once  an  opprobrium  on  the  profession  and  a  fatal 
injustice  to  the  sufferers;  who,  thus  abandoned  to  the  unre- 
strained progress  of  the  disease,  are  left  to  perish  by  a  lingering 
and  most  painful  process,  without  even  an  attempt  being  hazarded 
for  their  relief." 

The  foregoing  comparison,  instituted  by  Mr.  Bell,  between 
the  practice  of  the  French  and  English  surgeons  in  the  treat- 
ment of  tumors  of  the  maxillary  sinus,  is  certainly  correct.  But 
it  is  due  to  truth  to  say,  that  the  bold  practice  of  the  former  has 
been  fully  and  successfully  emulated  by  American  surgeons. 
Dr.  A.  H.  Stevens,  Professor  of  Surgery  in  the  University  of 
New  York,  in  1828,  in  a  case  of  fungous  tumor,  attached  by  a 
broad  base  to  the  lower  part  of  the  antrum,  removed  a  large 
portion  of  the  lower  and  anterior  parts  of  the  upper  jaw.  The 
patient  recovered,  and  is  said  to  be  living,  twenty  years  after 
the  operation.*  In  1841,  Dr.  J.  C.  Warren,  of  Boston,  for  a 
case  of  cephalomatous  tumor  of  this  cavity,  removed  the  superior 
maxillary  bone.  This  operation  was  also  successful. f  The 
same  operation  was  performed  soon  after,  and  for  the  removal 
-f  a  tumor  of  the  antrum  with  success,  by  Dr.  R.  D.  Mussey, 
of  Cincinnati  ;|  and  Dr.  Fare,  of  Columbia,  South  Carolina,  has 
performed  the  operation  twice  with  success. 

Thus  it  will  be  perceived,  that  the  disease  under  consideration 
not  unfrequently  calls  for  one  of  the  most  formidable  operations 

*  Appendix  to  Cooper's  Surgical  Dictionary,  p.  30. 
t  Boston  Medical  and  Surgical  Journal  for  1842. 
X  Western  Lancet  for  1842. 


564  TREATMENT   OF   TUMORS,    ETC. 

in  surgery,  and  that  by  it,  many  unfortunate  sufferers  have  been 
snatched  from  the  very  jaws  of  death.  The  application  of  the 
cautery,  however,  often  becomes  necessary  to  prevent  a  repro- 
duction of  the  excrescence,  and  there  are  many  cases  in  which 
it  cannot  be  repressed  even  by  this  means.  The  result  of  the 
most  thorough  and  best  directed  treatment  depends  on  the  state 
of  the  constitution  and  the  nature  of  the  disease.  In  depraved 
habits  and  shattered  constitutions,  if  the  tumor  is  of  a  carcinoma- 
tous character,  a  cure  need  never  be  expected. 

The  hemorrhage,  during  the  operation  for  the  removal  of  tu- 
mors of  the  antrum,  is  sometimes  so  profuse  as  to  require  very 
prompt  and  active  means  to  arrest  it.  It  may,  generally,  how- 
ever, be  controlled  by  the  employment  of  compresses  and  suit- 
able styptics ;  should  these  fail,  the  actual  cautery  must  be  re- 
sorted to. 

The  history  of  the  following  cases  taken  from  various  works, 
will  perhaps  furnish  a  more  correct  idea  of  the  methods  of  treat- 
ment most  proper  to  be  pursued  than  any  description  which  could 
otherwise  be  given.  The  first  three  cases  are  taken  from  the 
Memoires  de  1' Academic  Roy  ale  de  Chirurgie.* 

Case  15th.  A  man  about  thirty -five  years  of  age,  had  a  fleshy 
tumor,  the  size  of  a  large  pea,  situated  in  a  space  formed  by  the 
decay  of  the  first  and  second  superior  molars  of  the  left  side. 
This  tumor  caused  a  dull  pain ;  it  was  excised,  and  the  actual 
cautery  applied  to  arrest  the  bleeding  and  destroy  the  remaining 
portions  of  the  excrescence.  It  re-appeared,  and  three  months 
after  was  double  the  size  of  the  former,  and  impeded  mastication. 
The  two  decayed  teeth  were  loose,  and  the  others  were  painful ; 
and  fetid  matter  escaped  through  the  nose  and  mouth. 

After  the  extraction  of  the  two  decayed  teeth,  M.  Dubertraud, 
discovering  that  the  tumor  had  its  seat  in  the  antrum,  seized  it 
with  polypus-forceps  and  brought  the  whole  of  it  away.  After 
the  extraction  of  the  tumor,  the  opening  through  the  alveolus 
was  large  enough  to  admit  the  little  finger.  M.  Dubertrand 
next  destroyed  such  portions  of  the  alveoli  and  maxillary  bone 
as  were  decayed.  After  the  extirpation  of  the  tumor,  he  found 
it  necessary  to  introduce  a  plug  of  cotton  into  the  antrum,  to 
arrest  the  hemorrhage  that  followed  the  operation. 

«•  Tome  13,  obs.  1,  5  aud  7th,  pp.  372,  387  and  424. 


TREATMENT    OF   TUMORS,    ETC.  565 

The  secretions  of  the  maxill.ary  sinus  ceased  to  exhale  an  un- 
pleasant odor  ;  in  three  days  they  became  healthy,  and  in  less 
than  one  month,  the  patient  was  restored  to  health,  and  the  open- 
ing from  the  mouth  into  this  cavity  was  closed  with  firm  granu- 
lations. The  tumor  just  described  was  of  the  simple  non-malig- 
nant kind,  but  had  it  not  been  completely  eradicated,  it  would, 
doubtless,  have  soon  re-appeared. 

Case  16th.  Acoluthus  reports  the  case  of  a  woman  thirty 
years  of  age,  who,  in  1693,  came  to  Pologne  in  Silesia,  in  search 
of  aid  for  a  peculiar  disease  of  the  antrum,  under  which  she  was 
laboring.  Some  time  after  the  extraction  of  a  tooth  from  the 
left  side  of  the  upper  jaw,  a  small  tumor  appeared  in  its  alveolus, 
and  made  such  progress  that  in  two  years  it  attained  the  size  of 
the  doubled  fist.  It  occupied  nearly  the  whole  cavity  of  the 
mouth,  and  distended  the  jaw  to  such  a  degree  that  it  was  feared 
it  would  rupture  it.  The  lower  jaw  was  depressed,  the  lips  could 
not  be  made  to  meet,  and  the  tumor  increased  so  fast,  that  in  a 
few  weeks  the  woman's  life  was  despaired  of — being  threatened 
with  death  from  suff"ocation,  hunger  and  thirst.  Under  these 
circumstances,  Acoluthus  determined  to  attempt  a  cure. 

The  tumor  was  very  hard,  and  occupied  the  greatest  part  of 
the  palatine  arch ;  the  upper  teeth  of  the  left  side  were  in  its 
centre.  The  operation  was  commenced  by  enlarging  the  mouth, 
beginning  at  the  commissure  of  the  lips,  and  passing  it  trans- 
versely through  the  cheek.  This  enabled  Acoluthus  to  attack 
the  exterior  of  the  tumor  with  a  curved  bistoury.  The  excres- 
cence was  as  hard  as  cartilage,  and  scarcely  yielded  to  cutting 
instruments  applied  by  a  strong  hand.  He,  however,  succeeded 
in  removing  three  or  four  teeth,  together  with  a  portion  of  the 
superior  maxillary  bone.  The  operation,  as  yet,  had  extended 
only  to  the  external  half  of  the  tumor :  the  other,  which  filled 
the  palatine  fossa,  he  says,  it  was  impossible  to  bring  aAvay. 
The  removal  of  that  was  effected  only  by  piecemeal,  and  at  dif- 
ferent times.  The  operation  was  long,  laborious  and  very  pain- 
ful. The  actual  cautery  was  applied  to  the  bleeding  vessels  and 
fungous  flesh.  The  appearance  of  the  patient,  a  few  days  after 
the  operation,  was  such  as  to  inspire  hope  of  a  favorable  termi- 
nation of  the  disease.  The  actual  cautery  was  applied  several 
times,  and  finally  there  were  no  indications  of  the  re-appearance 


566  TREATMENT    OF    TUMORS,    ETC. 

of  the  excrescence,  except  at  the  point  where  it  had  first  origi- 
nated. Some  portions  of  bone  were  afterward  found  to  be  ca- 
rious, and  the  removal  of  these  was  followed  by  a  prompt  and 
speedy  cure. 

This  operation  is  alluded  to  by  M.  Velpeau,  as  embracing  the 
removal  of  the  entire  superior  maxillary  bone;  but  from  the  de- 
scription here  given,  it  would  appear  that  only  a  small  portion 
of  the  bone  was  taken  away.  The  alveolar  ridge  and  anterior 
parietes  of  the  sinus  only  were  removed.  The  history  of  the 
case,  however,  imperfect  as  it  is,  proves  that  the  resources  of 
art  are  adequate  to  the  cure  of  many  of  the  most  formidable 
of  the  affections  of  this  cavity,  if  they  are  not  delayed  too 
long. 

Another  case,  taken  from  the  Memoirs  of  the  Royal  Academy 
of  Surgery,  is  described  by  the  author  in  his  dissertation  on  the 
diseases  of  this  cavity ;  for  the  particulars  of  which  the  reader 
is  referred  to  page  131  of  that  work. 

Case  17th.  A  young  lady  of  Picardy  having  been  exposed  to 
the  changes  of  weather  for  three  years,  in  attending  to  business 
which  required  her  to  be  much  on  horseback,  experienced,  at  the 
end  of  the  first  year,  a  chilly  sensation  in  her  left  cheek ;  this 
increased,  and  the  cheek  became  swollen,  the  molar  teeth  of  the 
affected  side  loosened,  and  tAvo  dropped  out. 

The  swelling  of  the  cheek  increased,  and  she  was  affected  with 
lancinating  pains  in  that  side  of  the  face ;  the  breath  became 
offensive,  and  she  lost  two  more  teeth.  Becoming  alarmed,  she 
went  to  Rouen  to  obtain  medical  advice.  Receiving  no  satisfac- 
tion, she  went  to  Paris,  and  applied,  November  20th,  1740,  to 
M.  Croissant  de  Garengeot,  who  found  her  face  greatly  disfig- 
ured. Her  mouth,  he  says,  was  on  the  right  side,  the  left  side 
of  her  nose  much  elevated,  the  left  cheek  very  large,  and  the 
upper  lip  greatly  thickened.  Bluish  flesh  of  the  size  of  an  olive 
occupied  the  alveoli  of  the  teeth  which  had  dropped  out;  the 
left  side  of  the  roof  of  the  palate  was  thrown  inward,  and  re- 
sembled the  exterior  projection  of  the  cheek.  The  anterior  wall 
of  the  antrum  and  left  nasal  bono  had  become  softened,  and  the 
whole  cavity  was  filled  with  fungous  flesh. 

M.  Garengeot  commenced  the  operation  by  seizing  the  bluish 
excrescence  which  had  appeared  through  the  alveoli,  with  a 


i 


TREATMENT    OF    TUMORS,    ETC.  567 

hook  and  cutting  it  away;  and  he  says  he  incised  transversely, 
every  day,  from  within  the  mouth,  the  buccinator  muscle,  and 
brought  away  part  of  it,  as  well  as  the  flesh  which  so  much  aug- 
mented the  size  of  the  jaw. 

The  hemorrhage  was  so  abundant,  that  it  was  impossible  to 
proceed  further  with  the  operation.  The  excrescence  was  rapidly 
reproduced  after  each  operation ;  these  excisions  were  repeated 
seven  or  eight  times  in  six  weeks,  and  the  hemorrhage  each  time 
was  very  great.  The  seat  of  the  disease  was  in  the  anterior  of 
the  sinus.  The  fungous  flesh  contained  in  this  cavity  was  re- 
moved, as  well,  also,  as  some  osseous  projections. 

The  excrescence  continuing  to  be  reproduced,  the  patient  no 
longer  refused  to  have  the  actual  cautery  applied ;  the  use  of 
which  was  resorted  to  twice  a  day  for  eight  days.  The  success, 
says  M.  Garengeot,  which  followed  this  treatment,  was  incredible. 
The  flesh  soon  took  on  a  healthy  consistence,  about  two-thirds 
of  the  palatine  arch  returned  to  its  natural  situation,  and  the 
bad  odor  of  the  mouth  gradually  disappeared. 

The  application  of  the  cautery  was  continued  once  a  day  for 
three  weeks,  and  the  patient  did  nothing  more  than  to  use  a 
slightly  stimulating  and  astringent  gargle.  On  the  20th  of 
March  she  returned  home  cured. 

It  is  very  probable  that  had  the  first  operation  in  the  case  just 
described  been  thorough,  there  would  have  been  no  return  of  the 
disease,  for  it  is  evident  from  the  description  which  M.  Garengeot 
gives  of  the  operation,  that  the  seat  of  the  afiection  was  not 
reached  until  it  had  been  repeated  seven  or  eight  times ;  and 
then,  we  think  it  very  likely,  not  until  he  had  recourse  to  the 
actual  cautery. 

The  utility  of  the  actual  cautery,  not  only  for  the  purpose  of 
thoroughly  destroying  every  remaining  vestige  of  fungous  tumor 
of  the  antrum  after  their  removal,  but  also  for  the  suppression 
of  hemorrhage,  would  seem  to  be  fully  established  by  the  result 
of  the  treatment  of  cases  sixteen  and  seventeen. 

The  employment  of  arsenical  preparations  has,  in  some  in- 
stances, been  found  highly  advantageous  in  repressing  the  growth 
of  fungous  excrescences.  The  following  case  is  cited  by  Mr. 
Thomas  Bell  as  an  example.* 

*  Anat.  Physiol,  and  Diseaees  of  the  Teeth,  p.  283. 


568  TREATMENT    OF   TUMORS,    ETC. 

Case  18th.  "  James  Woodley  was  admitted  into  Guy's  Hos- 
pital September  4th,  1821,  for  a  fungous  exostosis  which  arose 
from  the  antrum  maxillare,  and  made  its  way  through  the  palate. 
After  his  admission  he  had  the  fungus  removed  two  or  three 
times,  and  a  variety  of  caustic  applications  were  afterward  made 
use  of,  notwithstanding  which  the  tumor  reappeared.  At  length 
Sir  A.  Cooper,  after  having  made  an  incision  from  the  corner  of 
the  mouth  outward  through  the  cheek,  removed  the  tumor  from 
a  greater  depth  than  had  previously  been  eifected.  After  this 
operation  the  wound  in  the  cheek  readily  healed,  and  the  follow- 
ing strong  solution  of  arsenic  was  daily  applied  to  the  part  from 
whence  the  tumor  had  been  removed. 

J^     Arsenic,  oxid.  alb.  5  ^i- 
Potass,  subcarb.  q.  s. 
Aq.  distillat. 

Misce  et  fiat  solutio. 

"  The  solution  required  to  be  diluted  in  the  first  instance  on 
account  of  its  occasioning  him  a  good  deal  of  pain  ;  in  a  few 
days,  however,  he  used  it  of  the  strength  mentioned  in  the  for- 
mula. It  was  applied  regularly  every  afternoon,  after  which  he 
did  not  take  any  food  until  the  following  day.  At  the  time  of 
its  application  he  had  a  piece  of  oiled  silk,  of  a  horse-shoe  shape, 
passed  into  the  mouth,  its  sides  being  turned  up  to  prevent  the 
solution  escaping  into  the  mouth ;  his  head  then  hanging  down  over 
a  basin,  a  piece  of  sponge  moderately  saturated  with  the  solution 
was  applied  to  the  disease  upon  the  oiled  silk,  and  pressed  against 
the  part ;  such  of  the  solution  as  was  then  pressed  out,  passed 
along  the  channel  of  the  oiled  silk  into  the  basin  over  which  the 
head  was  hanging,  and  the  saliva  escaped  behind  the  oiled  silk 
into  the  same  utensil.  He  kept  the  sponge  in  this  situation 
until  it  gave  him  considerable  pain,  when  it  was  removed  and 
the  mouth  carefully  washed.  He  sufl'ered  great  pain  in  his 
mouth  during  the  period  of  cure  ;  but  the  arsenic  did  not  pro- 
duce any  other  unpleasant  symptoms.  This  application  was 
continued  for  a  few  weeks,  at  the  end  of  which  time  he  was  com- 
pletely cured ;  a  cavity  was  left  in  the  site  of  the  tumor,  which, 
however,  gradually  became  covered  by  a  continuation  of  the 
membrane  which  naturally  lines  the  palate. 


TREATMENT    OF    TUMORS,    ETC.  560 

The  maxillary  sinus  is  sometimes  occupied  hj  fungous  tumors, 
originating  in  the  alveoli  of  the  molar  teeth,  or  from  the  roots 
of  these  teeth.  The  following  is  a  case  which  came  under  the 
observation  of  the  author  in  February,  1846: 

Case  19.     Miss  L ,  of  Baltimore,  aged  twenty-two,  of  a 

bilious  temperament,  called  to  consult  us  in  relation  to  the  con- 
dition of  her  teeth,  on  the  10th  of  February,  1846.  On  examina- 
tion, the  crowns  of  the  first  and  second  superior  molars  of  the 
left  side  were  found  badly  decayed,  and  from  the  destruction  of 
the  greater  portion  of  their  sockets,  much  loosened.  The  gums 
on  either  side  were  swollen,  spongy  and  had  a  livid  appearance ; 
from  between  the  edges  of  which,  whenever  the  teeth  were 
touched,  thin,  fetid  matter,  occasionally  streaked  with  blood  and 
pus,  was  discharged.  She  complained  of  a  sensation  of  fullness, 
and  occasionally  of  slight  pain  in  her  left  cheek.  The  affected 
molars  had  been  troublesome  and  sensitive  to  the  touch  for  nearly 
three  years ;  arising,  as  she  supposed,  from  a  severe  cold,  for 
about  that  time  she  suffered,  for  nearly  two  weeks,  the  most  vio- 
lent pain  in  these  teeth.  She  had  several  times,  subsequently, 
been  urged  by  her  friends  to  have  the  teeth  removed,  but  the 
dread  of  pain  had  prevented  her  from  submitting  to  the  opera- 
tion. 

Fearing  that  the  diseased  condition  of  the  sockets  of  the 
affected  molars  had  extended  to  the  antrum,  and  confident  that 
the  parts  immediately  involved  could  not  be  restored  to  health 
while  they  remained  in  the  mouth,  we  advised  her  to  have  them 
removed,  to  which,  after  much  persuasion,  she  consented. 

The  gums  being  separated  from  the  teeth,  we  grasped  the  first 
molar  with  a  pair  of  forceps,  and  proceeded  to  remove  it.  It 
readily  yielded  to  a  very  slight  force,  but  the  moment  this  was 
applied,  a  gush  of  blood  issued  from  the  left  nostril,  and  the  com- 
plete removal  of  the  tooth  was  prevented  by  a  fungous  excres- 
cence which  had  originated  at  the  extremity  of  its  roots,  and 
passed  up  into  the  antrum ;  the  true  nature  of  the  affection  at 
once  suggested  itself.  The' tooth,  after  being  partially  removed, 
was  liberated  by  cutting  the  excrescence. 

The  hemorrhage  for  a  few  minutes  was  profuse,  but  after  it 
had  partially  subsided,  the  socket  was  examined,  when  an  open- 
ing was  discovered  through  the  floor  of  the  antrum,  large  enough 


570  TREATMENT   OF   TUMORS,    ETC. 

to  admit  the  end  of  the  little  finger ;  the  fungous  peduncle,  after 
its  separation  from  the  roots  of  the  tooth,  having  contracted,  had 
passed  up  into  this  cavity.  This  was  now  partially  explored  by 
means  of  a  small  probe,  and  found  to  be  nearly  filled  with  a  soft 
spongy  tumor,  which  bled  profusely  from  the  slightest  injury. 
Finding  a  portion  of  the  floor  of  the  antrum,  back  of  the  tooth 
which  had  just  been  extracted,  in  a  necrosed  condition,  and  par- 
tially exfoliated,  M'e  extracted  the  second  molar,  (which  also  had 
a  fungous  excrescence  upon  the  extremity  of  its  roots,  passing  up 
through  an  opening  from  the  socket  into  this  cavity,)  and  then 
removed  the  dead  bone.  This  occupied  the  space  between  the 
two  teeth. 

An  opening  was  now  formed  through  the  floor  of  the  antrum, 
of  about  an  inch  in  length,  and  more  than  a  quarter  of  an  inch 
in  width,  which  enabled  us  to  explore  the  interior  of  the  cavity 
more  thoroughly  than  we  had  previously  been  able  to  do.  The 
tumor,  which  at  first  had  completely  filled  it,  had,  from  the 
hemorrhage  occasioned  by  the  laceration  of  the  vessels,  become 
so  reduced  in  size,  that  we  were  enabled  to  pass  a  small  curved 
probe  between  it  and  the  walls  of  the  sinus,  thus  proving  that  it 
had  no  connection  with  any  part  of  the  cavity.  There  was,  there- 
fore, no  danger  that  the  excrescence  would  be  reproduced  after 
its  removal,  which  was  done  piecemeal,  with  a  small  sharp-pointed 
hook,  and  a  narrow-bladed  knife.  The  opening  through  the 
alveolar  border,  in  the  antrum,  soon  closed,  and  the  parts,  in  a 
short  time,  were  restored  to  a  healthy  condition. 

What  would  have  been  the  result,  in  this  case,  had  the  teeth 
been  permitted  to  remain,  is  not  diflicult  to  conjecture.  The 
pressure  of  the  excrescence,  as  it  augmented  in  size,  would  have 
caused  necrosis  of  the  entire  floor  (if  not  of  the  walls  of  the 
antrum),  which  would  ultimately  have  become  displaced  and 
detached,  carrying  the  diseased  teeth  with  it.  But,  in  the 
meantime,  other  parts  might  have  become  involved  in  a  worse 
and  more  unmanageable  form  of  disease. 

In  the  treatment  of  tumors  of  this  cavity,  it  sometimes  becomes 

necessary  for  their  complete  eradication  to  remove  the  entire 

superior  maxillary  bone,  and  the  following  is  the  method  pursued 

by  Mr.  Liston  in  the  performance  of  this  formidable  operation : 

The  extent  of  the  disease  being  accurately  ascertained,  the 


TREATMENT    OF   TUMORS,    ETC.  571 

points  of  separation  are  decided  upon.  Supposing  the  malar 
bone  involved,  the  instruments  employed  are — a  pair  of  straitrht 
tooth  forceps,  a  full  sized  bistoury,  copper  spatula,  powerful 
scissors,  artery  forceps,  a  small  saw,  and  needles  for  interrupted 
and  twisted  sutures.  He  commences  the  operation  by  extracting 
a  central  incisor,  either  on  the  affected  side  or  the  opposite,  as 
the  size  of  the  tumor  may  require.  The  point  of  the  bistoury 
is  then  carried  from  the  external  angular  process  of  the  frontal 
bone  through  the  cheek  down  to  the  corner  of  the  mouth;  the 
incision  being  guided  by  placing  the  fore  and  middle  fingers  in 
the  cavity  of  the  mouth.  A  second  incision  is  made  along  the 
zygoma,  connecting  with  the  first.  The  knife  is  now  pushed 
through  the  integument  to  the  nasal  process  of  the  superior 
maxilla,  detaching  the  ala  from  the  bone,  and  cutting  through 
the  lip  in  the  median  line.  The  flap  is  dissected  up  and  held 
by  an  assistant;  the  inferior  oblique  muscle,  infra-orbital  nerve, 
and  other  soft  parts  attached  to  the  floor  of  the  orbit,  are  cut, 
and  supported  by  a  narrow  bent  spatula. 

The  section  of  the  bone  comes  next  in  order.  This  is  made 
with  the  cutting  forceps,  dividing  in  succession  the  junction  of 
the  malar  bone,  the  zygomatic  arch,  the  nasal  process  of  the 
superior  maxilla,  and  then  with  strong  scissors,  after  having 
notched  the  alveolar  process,  one  blade  is  passed  into  the  mouth, 
and  the  other  into  the  nostril  of  the  affected  side,  and  the  palatine 
arch  is  cut  through.  At  this  stage,  the  carotid  artery  is,  if 
necessary,  compressed.  The  tumor  is  now  turned  down  from  its 
bed,  and  the  remaining  attachments  divided,  preserving,  if  pos- 
sible, the  palatine  plate  of  the  palate  bone  with  the  velum  palati. 
The  branches  of  the  internal  maxillary  artery  being  torn  and 
stretched,  may  not  require  a  ligature.  The  patient  is  now 
placed  in  a  reclining  posture,  the  cavity  sponged  out  and 
examined,  and  all  vessels  that  are  seen,  whether  bleeding  or  not, 
are  secured  with  a  ligature,  and  the  ends  cut  off.  The  space 
occupied  by  the  tumor  and  removed  structures  are  filled  with 
lint,  and  the  edges  of  the  wound  united  with  either  the  inter- 
rupted or  twisted  suture.  No  dressing  is  applied,  plasters, 
bandages,  etc.,  being  thought  useless.  In  twenty-four  hours, 
some  of  the  sutures  are  withdrawn,  and  plasters  then  applied ; 
in  forty-eight  hours  they  are  all  removed,  the  wound  by  this 
time  having  adhered. 


572  TREATMENT    OF   TUMORS,    ETC. 

Other  methods  have  been  proposed  for  excision  of  the  upper 
jaw.  Fei'guson  begins  his  incision  from  the  margin  of  the  upper 
lip,  carries  it  to  the  nostril,  and  along  the  ala  to  within  half  an 
inch  of  the  inner  canthus;  a  second  incision  extends  from  the 
angle  of  the  mouth  to  the  zygomatic  process,  and  a  third  at  right 
angles  to  this  last,  extending  from  the  external  angular  process 
of  the  frontal  bone  toward  the  neck  of  the  lower  jaw.  Gensoul 
lets  fall  a  vertical  incision  from  near  the  inner  canthus,  and 
divides  the  upper  lip  entirely  through  over  the  canine  tooth ;  a 
tranverse  cut,  beginning  on  a  level  with  the  nostril,  extends  from 
this  to  the  forepart  of  the  lobe  of  the  ear.  A  third  incision, 
commencing  about  half  an  inch  from  the  outer  side  of  the 
external  canthus,  is  carried  down  almost  vertically,  and  touching 
the  outer  extremity  of  the  transverse  incision.  Two  flaps  are 
thus  formed,  the  one  superior  and  dissected  upward,  the  other 
inferior  and  turned  downward. 

Professor  Warren  and  M.  Velpeau  use  a  single  incision  similar 
in  shape,  and  extending  from  the  external  canthus,  at  its  tem- 
poral margin,  to  the  angle  of  the  mouth.  From  this  incision  a 
flap  is  dissected  upward  from  the  surface  of  the  bone,  the  ala 
detached  from  the  nose,  and  the  whole  turned  upward  toward 
the  forehead.  From  the  same  incision  another  flap  is  turned 
downward  sufiiciently  to  expose  the  malar  and  maxillary  bones. 

The  use  of  the  saw  and  cutting  forceps,  and,  if  necessary,  the 
chisel  and  mallet,  and  the  actual  cautery,  together  with  the  secu- 
ring of  the  arteries  by  ligature;  in  a  word,  the  dressing  of  the 
wound  in  all  these  diff'erent  ways  is  nearly  the  same  as  that  al- 
ready described.* 

There  are  a  number  of  highly  interesting  cases  of  sarcoma- 
tous, carcinomatous,  and  other  tumors  of  the  maxillary  sinus,  in 
Jourdain's  Treatise  on  the  Surgical  Diseases  of  the  Mouth;  some 
of  which  we  had  intended  to  introduce  into  this  book,  but  feared 
that  it  would  extend  it  to  too  great  a  length.  A  number  of 
equally  interesting  cases,  reported  in  various  other  works,f  are, 
for  the  same  reason,  excluded. 

*  Li^on's  Practical  Surgery ;  Ferguson's  Practical  Surgery;  Pancoast's  Operative 
Surgerj'j  Chelius'  System  of  Surgery,  and  Druit's  Surgeon's  Vade  Mecum. 

-f  Journal  de  Chirurgie,  torn,  i;  Parisian  Chirurgical  Jonrnal,  torn,  i;  (Euvres  Chir. 
de  Desault,  par  Bichat,  torn,  ii;  New  London  Med.  Jour.  vol.  i;  Eichorn.  Dis.  de 
Polypis  in  antro  Highmori.      Trans,  of  the  Society  for  the  Improvement  of  Med.  and 


TREATMENT    OF    TUMORS,    ETC.  573 

In  conclusion,  we  would  remark,  that  Professor  Pattison  pro- 
posed tying  the  carotid  artery,  in  1820,  for  the  dispersion  of 
fungous  tumors  of  the  maxillary  sinus.  He  was  induced  to  re- 
commend this  method  of  treatment  from  the  consideration,  that 
the  capability  of  action  of  a  part  is  proportioned  to  its  vascu- 
larity, and  that  by  thus  cutting  off  the  ciiculation  of  blood  to  it, 
the  morbid  growth  would  slough  and  be  thrown  off.  He  says 
this  practice  has  been  successful  where  it  has  been  adopted  in  all 
the  cases  that  had  come  to  his  knowledge.* 

Surg.  Knowledge.     Recueil  Periodique  de  la  Soc.  de  Med.,  torn,  ii;  No.  9,  Edinburgh 
Med.  and  Chir.  Jour.,  Nos.  83  and  84;    Traite   des   Maladies  Chirurgicales,  torn,  iv  : 
Traite  des  Maladies  des  Fosses  Nasales;  New  York  Jour,  of  Med.  and  Surgery;  West- 
ern Lancet;  Cooper's  Surgical  Dictionary;  Benj.  Bell's  Surgery,  vol.  iv,  &c. 
*  Appendix  to  Surgical  Anatomy  of  the  Head  and  Neck,  pp.  477-8. 


CHAPTER    EIGHTH. 

EXOSTOSIS  OF  THE  OSSEOUS  PARIETES  OF  THE  MAXIL- 
LARY SINUS. 

The  osseous  walls  of  the  maxillary  sinus  sometimes  become 
the  seat  of  bony  tumors — exostoses.  This,  however,  is  not  an 
affection  peculiar  to  the  bony  parietes  of  this  cavity ;  all  of  the 
osseous  structures  of  the  body  are  liable  to  be  attacked  by  it. 

Exostosis,  like  many  other  diseases,  presents  several  varieties. 
It  is  divided,  by  some  writers,  into  true  and  false,  the  one  con- 
sisting of  a  tumor  composed  wholly  of  bone,  or  nearly  so,  and 
the  other,  of  a  tumor  composed  both  of  ossific  matter  and  fun- 
gous flesh,  or  of  a  mere  thickening  of  the  periosteal  tissue.*  Sir 
Astley  Cooper  divides  exostosis  into  periosteal,  medullary,  car- 
tilaginous and  fungous.  The  first  consists  of  a  deposition  of 
bony  matter  on  "  the  external  surface  of  a  bone  and  the  internal 
surface  of  its  periosteum,"  and  to  both  of  Avhich  it  firmly  ad- 
heres. The  second  consists  of  *'  a  similar  formation,  originating 
in  the  medullary  membrane  and  cancellated  structure  of  the 
bone,"  this  description  of  exostosis  never  attacks  the  walls  of  the 
maxillary  sinus.  By  cartilaginous  exostosis  he  means,  "that 
which  is  preceded  by  the  formation  of  cartilage,  which  forms  the 
nidus  for  the  ossific  deposit."  Fungous  exostosis  he  describes 
to  be  a  tumor  not  so  firm  in  its  consistence  as  cartilage,  but 
harder  than  fungous  flesh,  having  interspersed  through  its  sub- 
stances spiculae  of  bone ;  it  has  a  malignant  character,  and  is  de- 
pendent upon  some  peculiar  constitutional  diathesis.  This  species 
of  exostosis  differs  but  little,  if  at  all,  from  osteo-sarcoma. 

Exostoses  differ  as  much  in  shape  as  they  do  in  structure. 
They  sometimes  rise  abruptly  from  the  surface  of  bones  by  a 
narrow  and  circumscribed  base,  projecting  in  large  irregularly 
or  spherically  shaped  masses ;  at  other  times  they  rise  very  gra- 
dually, covering  a  larger  surface  of  the  affected  bone,  but  less 

*Dictionaire  des  Sciences  Medicales,  t.  xvi,  p.  218. 


EXOSTOSIS    OF    THE    WALLS    OF    THE    ANTRUM.  575 

prominent  and  with  outlines  less  perfectly  defined.  An  exosto- 
sis has  been  known  to  occupy  the  whole  extent  of  the  surface  of 
a  bone.  "  The  whole  external  surface  of  one  of  the  bones  of  the 
skull  was  found  occupied  by  an  exostosis,  while  the  cerebral  sur- 
face of  the  same  bone  was  in  a  natural  state.*  Both  sides  and 
the  whole  thickness  of  bones  are  occasionally  affected  by  this  dis- 
ease.    This  is  what  Sir  Astley  Cooper  calls  periosteal  exostosis. 

This  disease  is  said  to  attack  some  bones  more  frequently  than 
others.  Those  of  the  skull,  the  lower  jaw,  sternum,  humerus, 
radius,  ulna,  femur,  tibia  and  bones  of  the  carpus  are  the  most 
subject  to  it.  It  also  very  frequently  attacks  the  upper  jaw ; 
in  fact,  none  of  the  bones  of  the  body  are  altogether  exempt 
from  it. 

The  texture  of  exostosis  is  sometimes  spongy  and  cellular,  at 
nther  times,  very  dense.  Dr.  E.  Carmichael,  a  distinguished 
surgeon  and  physician,  formerly  of  Fredericksburg,  described  to 
the  writer,  a  few  years  since,  an  exostosis  of  the  superior  maxilla, 
which  had,  a  short  time  before,  fallen  under  his  observation, 
larger  than  a  hen's  egg,  and  as  solid  as  ivory.  Exostosis  of  the 
roots  of  the  teeth  is  always  hard,  and  instances  are  sometimes 
met  with  of  osseous  tumors  upon  other  bones  possessed  of  nearly 
an  equal  degree  of  solidity.  Exostoses  of  this  description  grow 
less  rapidly  than  those  which  are  more  cellular  ;  but  they  some- 
times acquire  a  very  large  size.  It  is  not,  however,  uncommon 
for  such,  after  having  attained  a  greater  or  less  size,  to  cease  to 
grow,  and  "remain  stationary"  through  life,  without  giving  rise 
to  any  very  serious  or  unpleasant  consequences. 

Exostoses  sometimes  attain  an  enormous  size,  and  especially 
upon  cylindrical  bones;  very  large  ones,  too,  are  frequently  met 
with  upon  the  maxillge.  The  largest  one,  we  believe,  of  the 
maxillary  sinus,  of  which  medical  history  furnishes  any  account, 
is  exhibited  upon  a  specimen  of  morbid  anatomy,  presented,  in 
1767,  by  M.  Beaupreau,  to  the  French  Academy.  A  descrip- 
tion and  drawing  of  this  tumor  is  contained  in  the  Memoirs  ot 
the  Royal  Academy  of  Surgery,  but  we  have  no  account  of  the 
history  of  its  formation,  nor  of  the  symptoms  attending  it.  The 
tumor  occupies  the  whole  of  the  right  maxillary  sinus,  and  sev- 
eral of  the   neighboring  bones  are  involved  in   it.     It  is  very 

«  American  edition  of  Cooper's  Surgical  Dic-tinnary.  p.  :t62. 


576  EXOSTOSIS    OF    THE    WALLS    OF    THE    ANTRUM. 

large  near  its  base,  and  projects  from  the  lower  part  of  the  orbit, 
forward  and  downward,  six  inches.  Its  largest  circumference  is 
about  twelve  inches.  The  upper  part  of  the  maxillary  bone, 
sajs  Bordenave,  projects  on  the  side  of  the  orbit,  and  straightens 
the  cavity;  the  os  unguis  is  included  in  the  mass  of  the  tumor, 
and  is  represented  as  being  nearly  effaced.  The  nasal  bones  of 
the  left  side  are  displaced,  and  the  right  nostril  entirely  closed 
up,  and  the  exostosis  projects  so  much  on  the  left  side  as  to  be 
nearly  underneath  the  malar  bone.  The  inferior  part  of  the 
maxillary  bone,  says  our  author,  is"  so  extended  near  its  base, 
that  it  inclines  obliquely  to  the  left,  and  the  pterygoid  apophyses 
of  this  side  are  larger  than  those  of  the  other.  The  malar  bone 
is  described  as  being  involved  in  the  upper  and  external  part  of 
the  exostosis,  which  extends  to  the  left  maxillary  bone. 

Externally,  says  Bordenave,  the  tumor  had  a  smooth  and  pol- 
ished appearance ;  its  upper  part  was  very  hard ;  below,  its  sub- 
stance had  become  thinner,  was  deficient  in  some  places,  and  the 
interior  of  the  exostosis  was  exposed.  The  substance  of  the  bone 
was  spongy  and  porous,  and,  in  appearance,  not  unlike  pumice- 
stone.  The  walls  were  thick,  and  measured,  in  some  places,  one 
inch.* 

From  this  brief  description,  taken  from  an  account  given  by 
Bordenave,  some  idea  may  be  formed  of  the  dimensions  and  ap- 
pearance of  this  enormous  and  most  remarkable  exostosis. 

A  case  of  exostosis  of  each  antrum  is  described  by  Sir  Astley 
Cooper,  both  of  which  forced  themselves  up  into  the  orbits,  and 
pushed  the  eyes  from  their  sockets.  One  made  its  way  into  the 
brain,  and  caused  the  death  of  the  patient. f 

Mr.  Thomas  Bell  does  not  believe  in  the  occurrence  of  ''true 
exostosis  upon  the  bony  parietes"  of  this  cavity,  but  too  many 
examples  have  presented  themselves,  to  leave  any  room  for 
doubt  upon  the  subject.  Although  none  may  ever  have  fallen 
under  his  own  immediate  observation,  there  are  many  well  au- 
thenticated cases  on  record;  but,  apart  from  these,  we  think  it 
would  be  difficult  to  assign  any  sound  reasons  for  supposing  that 
the  osseous  walls  of  this  cavity  should  be  more  exempt  from  the 
disease  than  other  bones  of  the  body. 

-•»  Memoires  de  1'  Academic  Royalc  de  Chirurg.,  t.  xiii,  ob3.  xii,  p.  412. 
"("  Surgical  Essays,  part  i,  p.  15". 


CAUSES    OF    EXOSTOSIS.  577 


SYMPTOMS. 


Exostosis  of  the  walls  of  the  maxillary  sinus  is  generally  so 
insidious,  that  the  presence  of  the  disease  is  not,  for  a  long  time, 
even  suspected.  When  it  results  from  venereal  vice,  Boyer 
says,  it  is  preceded  by  acute  pain,  extending  at  first  to  almost 
every  part  of  the  bone,  but  afterward  confining  itself  to  the 
afi'ected  portion.  When  it  is  occasioned  by  scrofula,  the  same 
writer  tells  us,  it  is  attended  by  a  duller  and  less  severe  pain; 
the  symptoms  of  exostosis  resulting  from  causes  purely  local — 
such,  for  example,  as  a  blow — are  very  similar.*  These  signs 
are  common  to  the  disease  wherever  it  may  be  situated,  and  when 
it  is  seated  in  the  maxillary  sinus,  they  do  not  distinguish  it 
from  many  of  the  other  afi'ections  that  occur  here.  Further- 
more, the  disease  not  unfrequently  gives  rise  to  symptoms  at- 
tendant upon  several  of  the  other  affections  of  this  cavity,  so 
that,  previously  to  the  distension  of  its  walls,  it  may  be  con- 
founded with  inflammation  of  the  lining  membrane,  or  with  sar- 
comatous or  other  tumors.  After  it  has  filled  the  sinus,  or  very 
considerably  thickened  its  exterior  walls,  it  will  cause  them  to 
oifer  a  firmer  resistance  to  pressure  than  any  of  the  other  dis- 
eases of  this  cavity.  When,  therefore,  they  have  become  dis- 
tended, if  they  are  firm  and  unyielding  to  pressure,  the  presence 
of  exostosis  may  be  inferred. 

CAUSES. 

There  is  a  difference  of  opinion  among  writers  on  the  diseases 
of  bones,  with  regard  to  the  causes  of  exostosis.  Certain  con- 
stitutional diseases,  such  as  "scrofula  and  lues  venerea,"  are 
thought  by  some  to  give  rise  to  the  affection.  That  the  last  of 
these  diseases  is  fiivorable  to  its  production,  is  we  believe,  ad- 
mitted by  all ;  but  Sir  Astley  Cooper  declares  that  no  evidence 
has  yet  been  adduced  to  prove  that  the  former  is  ever  concerned 
in  its  production.  Others  impute  the  disease  to  local  irritation 
produced  by  contusions,  fractures,  &c.  It  is  probably  dependent 
upon  both  local  and  constitutional  causes,  neither  being  capable, 
independently  of  the  other,  of  producing  it. 

«Traite  des  Maladies  Chirurgicales,  t.  iii,  p.  545. 


578  TREATMENT    OF    EXOSTOSIS. 


TREATMENT. 

A  variety  of  plans  has  been  recommended  for  the  treatment 
of  this  disease ;  and  Bordenave  assures  us  it  may  be  cured,  if 
suitable  remedies  are  applied  before  it  has  acquired  much  solidity. 
Assuming  that  it  sometimes  results  from  constitutional  causes, 
he  directs  that  the  treatment  should  be  commenced  by  the  em- 
ployment of  such  means  as  are  indicated  by  the  nature  of  the 
vice  with  which  the  patient  may  be  affected.  If  a  venereal  vice 
be  present,  the  use  of  mercurial  medicines  are  recommended. 
The  author  last  mentioned  says,  he  has  known  it  to  be  success- 
fully treated  with  mercury.  Topical  applications,  such  as  fomen- 
tations and  cataplasms,  have  also  been  found  serviceable.  Boyer 
advises  poultices  of  linseed  meal,  and  a  decoction  of  the  "  leaves 
of  henbane  and  nightshade."  Iodine  and  mercury  have  been 
employed,  but  not,  we  believe,  with  any  decided  advantage.  Sir 
Astley  Cooper  thinks  the  best  internal  remedy  is  "  oxymuriate 
of  mercury,  together  with  the  compound  decoction  of  sai'sa- 
parilla."  We  believe,  with  Boyer,  that  a  dispersion  of  an  ex- 
ostosis can  never  be  effected.  Its  progress  may,  perhaps,  be 
partially  arrested,  but  we  do  not  believe  that  it  is  ever  taken  up 
by  the  absorbents.  It  is  not  advisable  to  remove  an  exostosis, 
unless  it  continues  to  augment  and  is  likely  to  become  dangerous, 
or  is  productive  of  serious  inconvenience. 

When  the  remedies  which  have  been  mentioned,  after  having 
been  thoroughly  tried,  prove  unsuccessful,  and  it  becomes  neces- 
sary to  remove  the  exostosis,  the  tumor  should  be  fully  exposed  ; 
first,  by  the  dissection  of  the  gum  and  other  soft  parts  from  the 
exterior  walls  of  the  sinus,  and,  second,  by  the  perforation  of 
this  cavity  with  a  trephine,  or  such  other  instrument  as  can  be 
most  conveniently  employed.  This  part  of  the  operation,  though 
simple,  should  be  conducted  with  care.  If  the  tumor  is  large 
and  attached  by  a  very  broad  base,  its  removal  will  sometimes 
prove  more  difficult ;  yet  by  means  of  suitably  constructed  saws, 
scissors,  knives,  &c.,  it  may,  in  most  instances,  be  accomplished, 
^n  external  wound  through  the  cheek  should  always,  if  possible, 
be  avoided. 

The  method   of  operating,  however,  will  be   best  understood 


TREATMENT    OF    EXOSTOSIS.  579 

by  a  description  of  that  pursued  in  the  two  following  cases.  The 
first  was  treated  by  Dr.  B.  A.  Rodrigues,  dentist,  of  Charleston, 
S.  C,  and  reported  by  him  for  the  American  Journal  of  Medical 
Sciences. 

Case  21st.  "  On  the  14th  of  August,  1837,  Charity,  a  servant 
woman  of  Mrs.  Miller,  called  on  me  to  ascertain  whether  I  could 
afford  her  any  relief  in  her  wretched  condition.  She  had  been 
laboring  under  incessant  and  agonizing  pain  in  the  antrum  high- 
morianum  of  the  right  side,  which  she  regarded  as  the  conse- 
quence of  the  impaired  condition  of  the  teeth.  On  this  supposi- 
tion, she  had  several  of  them  extracted,  without  any  appreciable 
abatement  of  her  sufferings.  Yet,  deluded  with  the  belief  that 
some  one  of  the  remaining  teeth  was  the  secret  agent  of  all  she 
suffered,  she  persisted  in  having  more  extracted.  Still,  the  evil 
continued,  the  suffering  was  unabated,  the  cause  undetected ;  and 
to  add  to  the  depression  of  her  hopes,  and  the  aggravation  of 
her  ills,  a  purulent  discharge  oozed  from  the  empty  sockets  of 
the  affected  side.  She  again  had  recourse  to  medical  advice, 
hoping  that  this  phasis  of  her  malady  might  lead  to  some  indica- 
tions that  would  relieve  her ;  at  least,  that  it  might  reveal  its 
hidden  sources,  its  condition,  and  its  prospect  of  being  remedi- 
able. And  here,  for  the  first  time,  was  it  suggested  that  the 
antrum  was  in  an  unsound  state. 

"  It  was  at  this  moment,  under  these  circumstances,  that  she 
applied  to  me  to  perform  an  operation,  which  her  medical  adviser 
declared  to  be  indispensable.  At  first,  I  imagined  it  to  be  an 
abscess  from  which  the  pus  Avas  discharged,  because  of  the  strange 
sensations  experienced,  and  the  greater  frequency  of  this  disease 
over  others  peculiar  to  this  part.  I  inserted  a  trocar  into  the 
socket  of  the  second  molar,  and  instead  of  the  gush  of  matter  I 
had  expected,  the  passage  of  the  instrument  was  intercepted  by 
a  hard,  dense,  impervious  substance.  The  existence  of  an  exos- 
tosis now  forced  itself  on  me.  To  make  assurance  doubly  sure, 
I  had  access  to  several  of  my  medical  friends,  among  whom  was 
Dr.  Geddings.  On  examination  of  the  part,  the  consideration 
of  the  symptoms,  and  the  obstinate  nature  of  the  disease,  they 
concurred  with  me  in  opinion,  that  an  exostosis  was  present,  and 
that  the  sole  indication  of  relief  was  its  extirpation.  Accord- 
ingly, on  the  18th  of  August,  these  gentlemen,  with  several  others 


580  TREATMENT    OF    EXOSTOSIS. 

of  the  profession,  were  present  when  I  proceeded  to  perform  the 
operation.  With  a  common  scalpel,  I  dissected  away  the  gum 
from  the  canine  tooth  to  the  last  molar,  raised  the  flap  which  it 
made  from  the  alveolar  process,  and  with  a  trephine  opened  into 
the  cavity.  Success  was  easier  than  had  been  anticipated,  in 
consequence  of  the  carious  condition  of  the  bone,  which  was  so 
general  on  the  aff'ected  side,  as  to  reach  from  the  second  incisor 
anteriorly  to  the  pterygoid  process  posteriorly.  The  external 
parietes  of  the  cavity  shared  in  the  loss  of  substance,  so  that 
the  bony  tumor  which  filled  up  and  occupied  it,  could  be  readily 
reached.  The  trephine  was  applied,  the  cavity  enlarged,  and 
the  exostosis  removed.  It  measured  in  circumference  three 
inches,  was  light,  and  cancelated  on  its  surface,  but  dense  and 
more  resisting  in  its  internal  layers.  There  was  little  or  no 
hemorrhage  to  delay  the  operation,  or  any  application  necessary 
to  arrest  it.  After  removing  every  spiculum  of  diseased  bone, 
and  cleansing  out  tlie  cavity,  the  flap  was  replaced,  and  the  cure 
was  entrusted  to  nature.  Granulations  sprouted  up  in  full  luxu- 
riance, and  in  the  short  period  of  four  weeks,  the  woman  was  in 
the  enjoyment  of  excellent  health."* 

That  the  foregoing  was  a  case  of  true  exostosis  of  the  maxillary 
sinus,  does  not  admit  of  doubt ;  and  it  is  to  be  regretted,  that 
there  is  not  more  of  the  early  history  of  the  disease,  and  the 
circumstances  connected  with  its  development.  They  might, 
perhaps,  lead  to  a  correct  explanation  of  the  causes  that  gave 
rise  to  it.  The  presence  of  local  irritants  in  the  immediate 
vicinity  of  this  cavity,  is  proven  by  the  fact  that  the  patient's 
teeth  were  in  a  diseased  condition ;  but  to  what  extent  they  may 
have  contributed  to  the  production  of  exostosis  it  is  impossible 
to  determine,  since  we  are  not  furnished  with  any  information 
concerning  the  state  of  her  general  health.  She  may  have  been 
afiected  with  some  constitutional  vice,  or  peculiar  habit  of  body, 
whereby  the  osseous  structures  of  the  system  were  predisposed 
to  aff'ections  of  this  description  ;  requiring  only  the  presence  of 
some  local  irritant  to  induce  the  morbid  action  necessary  to  their 
development.  If  all  the  circumstances  connected  with  the  previ- 
ous history  of  the  case  could  be  ascertained,  they  would,  we  be- 
lieve, show  that  such   predisposition   did   exist,  and  that  such 

*"  American  Journal  of  Medical  Science. 


TREATMENT    OF    EXOSTOSIS.  581 

action  was  excited  by  the  irritation  produced  by  the  diseased 
teeth. 

When  the  exostosis  is  so  situated  as  to  prevent  its  complete 
removal,  the  application  of  the  actual  cautery  to  any  remaining 
portions  will  prove  serviceable,  by  causing  such  parts  to  exfoliate. 
The  history  of  a  case  is  related  by  M.  Bordenave,  as  treated  by 
M.  Runge,  in  which  a  portion  of  the  extostois  was  left,  and 
Avhich  ultimately  caused  the  death  of  the  patient.  This  would 
probably  have  been  prevented,  had  an  exfoliation  of  the  remain- 
ing diseased  portion  of  bone  been  brought  about  by  an  applica- 
tion of  the  actual  cautery. 

Case  22d.*  The  subject  of  this  case  was  a  man  33  years  of 
age.  He  had  been  for  a  long  time  afflicted  with  a  tumor  in  the 
region  of  the  right  antrum.  It  depressed  the  palatine  process 
of  the  maxillary  bone  and  the  palate  bone  of  the  affected  side 
in  such  a  manner  as  to  restrict  the  movements  of  the  tongue, 
Avhile  on  the  other  side  it  pressed  against  the  floor  of  the  orbit 
so  as  to  cause  a  protrusion  of  the  eye.  Anteriorly,  it  had  ele- 
vated a  portion  of  the  maxillary  and  malar  bones  which  covered 
it,  and  extended  to  the  most  dependent  part  of  the  nose,  extend- 
ing backward  as  far  as  the  posterior  mouth:  it  also  exerted 
similar  pressure  and  displacement  in  a  lateral  direction. 

After  having  exposed  the  anterior  parietes  of  the  antrum,  M. 
David  could  see  the  uppermost  part  of  the  projection  of  the 
tumor,  which  was  of  a  spherical  shape,  and  nearly  three  inches 
in  diameter;  and,  after  having  elevated  this  part,  he  discovered 
the  tumor,  which  was  white  and  hard,  although  spongy,  and 
occupied  the  whole  cavity,  changing  its  form  and  increasing  its 
dimensions  to  an  extraordinary  degree.  The  greater  portion  of 
this  hard  osseous  substance,  although  firmly  adhering  to  almost 
every  part  of  its  bony  envelope,  was  detached  by  a  persevering 
employment  of  various  means,  such  as  the  crotchet,  elevator, 
surgeon's  rasp,  etc.  In  doing  this,  he  inflicted  some  injury  upon 
the  floor  of  the  orbit;  and  to  some  portions  of  exostosis  which 
still  adhered  to  the  palatine  process  of  the  maxillary  bone,  he 
several  times  applied  the  actual  cautery. 

An  opening  was  formed  by  this  operation  four  and  a  halt 
inches  deep,  and  from  right  to  left  more  than  three  inches ;  but 

»  Memoires  de  I'Acadeinie  Royale  de  Chirurg.,  t.  xiii.,  obs.  xi.,  p.  408. 


582  TREATMENT    OF    EXOSTOSIS. 

the  use  of  the  cautery  speedily  effected  a  cure,  which  would  not 
perhaps  have  been  otherwise  successful. 

Exostosis  of  the  maxillary  sinus  often  gives  rise  to  other 
morbid  conditions  of  this  cavity,  the  remedial  indications  of 
which  should  be  properly  attended  tO;,  as  should  also  those  of 
any  constitutional  affection,  vice,  or  habit  of  body  that  the 
patient  may  be  laboring  under  at  the  time.  When,  however, 
the  exostosis  is  not  complicated  with  any  other  disease  of  the 
cavity,  the  restorative  energies  of  nature  will  generally  be  all 
that  is  required,  after  its  removal,  to  complete  the  cure. 


1 


CHAPTER    NINTH. 

WOUNDS  OF  THE  OSSEOUS  PARIETES  OF  THE 
MAXILLARY  SINUS. 

The  walls  of  the  maxillary  sinus  are  sometimes  fractured  by 
blows  and  pierced  by  sharp-pointed  instruments.  Fauchard 
mentions  a  case,  in  which  a  canine  tooth  had  been  driven  up  into 
it.*  This  is  an  accident  that  rarely' happens.  The  instance  here 
alluded  to,  is,  we  believe,  the  only  one  on  record  ;  and,  as  might 
be  supposed,  it  was  followed  by  severe  pain,  and  ultimately  gave 
rise  to  a  tumor  upon  the  cheek  near  the  nose,  with  three  fistulous 
openings,  from  which  fetid  matter  was  discharged.  The  sinus 
having  been  opened,  and  the  tooth  taken  from  it,  a  cure  was  at 
once  effected. 

It  often  happens  that,  when  the  walls  of  the  sinus  are  fractured 
by  a  blow  or  other  mechanical  violence,  portions  of  the  bone  and 
foreign  bodies  are  driven  into  the  cavity  ;  these,  remaining  there, 
become  a  constant  source  of  irritation  to  the  lining  membrane, 
and,  not  unfrequently,  a  hidden  cause  of  other  and  more  malig- 
nant forms  of  disease.  Bordenave  describes  the  case  of  a  French 
oflScer,  who  had  the  walls  of  the  maxillary  sinus  fractured  by  a 
fragment  of  a  bomb-shell.  Dressings  were  applied  to  the  wound, 
but  it  did  not  heal ;  upon  examination  sometime  after  by  M. 
AUouel,  several  pieces  of  bone  and  a  splinter  Avhich  nearly  filled 
the  cavity  were  found.  These  were  removed,  but  a  cure  was  not 
immediately  effected;  a  fistulous  opening  still  remained,  and  it 
was  not  until  a  long  time  after,  when  another  splinter  came  away, 
that  the  external  opening  healed.  The  same  writer  mentions  the 
case  of  a  man  who  had  a  nail  forced  head  foremost,  by  the  dis- 
charge of  a  gun,  into  his  right  cheek  and  maxillary  sinus.  The 
opening  became  fistulous,  and  although  the  point  of  the  nail  was 
subsequently  discharged,  it  was  not  until  M.  Faubert  had  removed 
the  remaining  part,  that  the  fistula  closed. 

»  Le  Chirurgien  Dentiste,  torn,  i,  page  391. 


584  TREATMENT    OF    WOUNDS    OF    THE    ANTRUM. 

Contused  wounds  of  the  antrum  are  often  complicated  with 
fracture  of  the  osseous  parietes ;  so  that  the  effects  resulting  ; 
from  them  are  more  to  be  dreaded  than  those  which  would  be  9 
produced  simply  by  the  penetration  of  a  sharp  instrument. 

TREATMENT. 

The  nature  and  extent  of  the  injury  inflicted,  should  determine 
the  treatment  most  proper  to  be  adopted  for  wounds  of  this  cavity. 
Complicated  as  they  in  most  instances  are  by  the  presence  of  ex- 
traneous substances,  the  removal  of  these  constitutes  the  first, 
and  not  unfrequently,  the  only  remedial  indication  ;  therefore 
when  any  extraneous  bodies,  or  portions  of  bone,  have  been 
forced  into  the  sinus,  they  should  all  be  carefully  removed.  The 
external  wound  may  next  be  dressed  with  adhesive  slips  to  pre- 
vent the  formation  of  an  unsightly  cicatrix.  If  constitutional 
symptoms  supervene,  they  should  be  met  with  appropriate  reme- 
dies. 

The  following  interesting  case  of  a  wound  of  the  maxillary 
sinus,  inflicted  with  a  dirk-knife,  treated  by  W.  H.  Donne,  M.D., 
of  Louisville,  Ky.,  is  taken  from  the  "  Western  Journal  of  Medi- 
cine and  Surgery  :'* 

Case  23d.  "  Schuti,  a  gardener,  aged  forty-two  years,  a  native 
of  Germany,  in  a  rencontre  with  an  athletic  man,  on  the  3d  of 
May,  1840,  was  struck  with  a  dirk-knife,  which  entered  about 
an  inch  above  the  right  superciliary  arch,  passed  through  the 
corresponding  eyelid  downward  and  backward,  evacuating  the 
humors  of  the  eye,  and  penetrating  the  *antrum.  The  globe  of 
the  eye  was  divided  by  a  vertical  incision,  through  Avhich  the 
aqueous  humor  escaped  ;  the  iris  was  extensively  detached  at  the 
ciliary  margin,  and  could  be  partially  seen  through  the  trans- 
parent cornea,  its  surface  being  somewhat  obscured  by  small 
coagula.  The  hemorrhage  was  slight  and  easily  controlled  by 
moderate  pressure.  The  patient  complained  of  intense  pain  in 
the  temple  and  cheek  of  the  wounded  side  shooting  far  into  the 
orbit.  Three  points  of  interrupted  suture  were  used  to  approxi- 
mate the  edges  of  the  divided  eye.  Lint,  saturated  with  lauda- 
num and  warm  water,  constituted  the  dressing. 

"May  4th.  Some  tumefaction  in  the  eyelid;  pulse  110;  tongue 


TREATMENT    OF    WOUNDS    OF   THE    ANTRUM.  585 

coated  and  dry ;  skin  hot ;  patient  had  spent  a  very  restless 
night.  Ordered  following  medicine:  tart,  emetic,  gr.  i. ;  sulph. 
magnesije,  5ss. ;  to  be  dissolved  in  one-half  pint  of  water,  and  a 
table-spoonful  to  be  taken  every  half-hour,  until  nausea  is  in- 
duced; after  which  the  interval  may  be  increased. 

"May  5th.  Bowels  freely  evacuated;  pain  less;  skin  moist; 
pulse  90  and  soft.  From  this  period  until  the  wound  healed — 
a  space  of  three  weeks — no  constitutional  symptoms  of  an  unto- 
ward character  occurred.  The  patient,  however,  contended  that 
a  portion  of  the  knife-blade  remained  in  the  roof  of  his  mouth. 
But,  on  the  most  careful  examination,  no  foreign  body  could  be 
detected. 

"  On  the  10th  of  August,  1842,  Mr.  Schuti  called  and  re- 
quested Dr.  Donne  to  examine  his  mouth,  stating  that  for  six 
months  past  he  had  been  annoyed  by  a  rough,  projecting  sub- 
stance, which,  some  person  had  informed  him,  was  a  piece  of 
dead  bone,  but  which  he  believed  to  be  the  point  of  the  knife, 
that  had  been  driven  down  into  the  bone  by  the  violence  of  the 
blow.  On  looking  into  the  mouth,  a  small  black  speck  was  dis- 
cernible about  one-half  inch  from  the  interval  between  the  first 
and  second  molar  teeth.  The  parts  adjacent  were  somewhat 
tumefied  and  inflamed.  Dr.  Donne  made  several  attempts  to 
extract  this  body  Avith  a  pair  of  common  dissecting  forceps,  but 
found  it  immovably  fixed  in  the  substance  of  the  bone.  By  dis- 
secting around  it  with  a  bistoury,  down  to  the  palate  process  of 
the  superior  maxillary  bone,  he  was  enabled  to  get  a  firmer  hold, 
and,  with  a  pair  of  curved  tooth-forceps,  succeeded  in  removing 
a  fragment  of  the  blade,  one  and  one-fourth  inches  in  length  and 
three-fourths  in  width  at  the  widest  part;  the  extraction  was 
not  eflfected  without  considerable  violence,  and  was  attended 
with  extreme  suS^ering.  The  fragment  came  out  with  an  audible 
snap,  which  induced  those  present  to  suppose,  at  first,  that  it 
had  been  broken ;  but,  on  inspecting  its  surface  closely,  no  evi- 
dence of  recent  fracture  could  be  seen.  Upon  probing  the 
aperture  through  which  the  fragment  had  been  extracted,  no 
other  piece  could  be  detected.  This  opening  would  scarcely  ad- 
mit the  curved  probe,  which  Dr.  Donne  passed  into  the  antrum, 
in  order  to  satisfy  himself  that  the  whole  of  the  foreign  body 
was  removed.     The  next  day  there  was  a  slight  discharge  from 


586       TREATMENT  OF  WOUNDS  OP  THE  ANTRUM. 

the  aperture,  though  the  patient  has  suffered  very  little  pain 
since  the  operation." 

The  foregoing  is  certainly  one  of  the  most  singular  cases  of 
which  we  have  any  account,  and  the  most  remarkable  circum- 
stance connected  with  it  is,  that  no  more  injury  should  have  re- 
sulted from  the  presence,  for  so  long  a  time,  in  the  maxillary 
sinus,  of  the  fragment  of  the  dirk.  In  the  cases  previously  no- 
ticed, as  reported  by  Bordenave,  disease  of  the  mucous  mem- 
brane of  the  antrum  and  the  discharge  of  fetid  sanies  resulted 
from  the  presence  of  the  foreign  bodies  in  this  cavity.  The 
same  effect  was  also  produced  in  the  case  described  by  Fauchard, 
where  the  canine  tooth  had  been  forced  up  into  the  antrum. 


CHAPTER    TENTH. 
FOREIGN  BODIES  IN  THE  MAXILLARY  SINUS. 

That  foreign  bodies  are  sometimes  admitted  into  the  maxillary 
sinus  through  wounds  penetrating  its  exterior  parietes,  has 
already  been  shown,  but  that  they  should  gain  access  to  it  in  any 
other  way,  would  seem  almost  impossible.  The  smallness  and 
peculiar  situation  of  the  nasal  opening  which  communicates  with 
it,  one  might  think,  would  preclude  the  introduction  of  extra- 
neous substances  of  any  kind  through  it ;  yet  they  have  been  found 
here  when  they  could  have  gained  admission  in  no  other  way. 
There  are  several  well  authenticated  cases  on  record  in  which 
worms  have  been  found  in  this  cavity.  But  the  case  mentioned 
by  Bordenave,  in  the  Memoirs  of  the  Royal  Academy,  of  a  dis- 
eased maxillary  sinus,  from  which  several  worms  were  at  different 
times  discharged,  does  not  prove  that  they  obtained  admission 
into  it  through  the  nasal  opening ;  for  in  this  case,  a  fistulous 
opening  from  the  cavity  had  existed  for  a  long  time  previously 
to  the  discharge  of  the  worms,  and  it  is  very  probable  that  they 
introduced  themselves  through  this  opening.  A  cause  suflficient 
to  have  produced  the  disease  in  the  sinus  had  been  operating  for 
two  years,  immediately  preceding  its  manifestation,  the  patient, 
during  the  whole  of  this  time,  having  been  affected  with  pain  in 
the  superior  teeth  of  the  affected  side. 

Deschamps,  says  his  colleague  in  la  Charite  Hospital,  found 
a  worm  four  inches  long  in  the  maxillary  sinus  of  a  soldier, 
whom  he  was  dissecting ;  and  the  same  writer  informs  us  that  a 
similar  example  is  furnished  in  the  Journal  of  Medicine.  The 
particulars  of  a  case  which  came  under  the  observation  of  Mr. 
Heysham,  physician,  of  Carlisle,  England,  arc  contained  in 
Cooper's  Surgical  Dictionary.  The  subject  of  this  case  was  a 
strong  woman,  sixty  years  of  age,  who  was  in  the  habit  of  taking 
a  great  deal  of  snuff.  She  was  affected  for  a  number  of  years 
■with  severe  pain  in  the  region  of  the  maxillary  sinus,  which  ex- 


588  FOREIGN    BODIES    IN    THE    ANTRUM. 

tended  over  one  side  of  the  head.  She  was  never  entirely  free 
from  this  pain,  but  it  was  greater  in  cold  than  in  warm  weather. 
For  the  purpose  of  obtaining  relief,  she  had  been  twice  salivated, 
and  had  taken  various  anodyne  medicines ;  the  pain,  however, 
instead  of  being  mitigated  by  these  means,  became  more  severe, 
Her  teeth  on  the  affected  side  were  all  extracted,  and  as  a  last 
resort  the  maxillary  sinus  was  perforated.  This  for  several  days 
did  not  give  any  relief.  Injections  of  bark  and  "  elixir  of  aloes," 
were  thrown  into  it,  and  on  the  fifth  day  a  dead  insect,  more 
than  an  inch  in  length  and  as  thick  as  a  goose  quill,  was  removed 
from  this  cavity. 

Instances  of  the  introduction  of  insects  or  foreign  bodies  of 
any  description  into  the  antrum,  through  the  nasal  opening,  for- 
tunately, are  so  exceedingly  rare,  that  the  Memoirs  of  Medicine 
do  not  furnish  more  than  four  or  five  well  established  examples. 
The  great  annoyance  and  distress  which  their  presence  in  the 
nasal  and  communicating  cavities  may  occasion,  proves  the 
"  wisdom  of  design"  in  the  growth  of  hairs  found  just  inside  the 
nostrils.  "Were  it  not  for  these,  as  this  aperture  is,  unlike  the 
mouth,  permanently  open,  insects  might  pass  in  during  the  un- 
guarded hours  of  sleep. 

The  signs  indicative  of  -the  presence  of  insects  or  foreign 
bodies  in  the  maxillary  sinus,  are  so  obscure,  that  the  fact  can 
only  be  ascertained  Ijy  perforating  the  cavity  and  by  examination 
of  its  interior.  Some  say  that  foreign  bodies  here  cause  an  itch- 
ing, crawling  or  tickling  sensation  in  the  substance  of  the  cheek. 
This  is  an  uncertain  diagnosis,  for  such  sensations  are  not  un- 
frequent  in  the  region  of  this  cavity.  That  they  sometimes  cause 
great  pain,  is  proven  by  the  history  of  the  case  related  by  Mr. 
Heysham,  the  particulars  of  which  we  have  just  noticed.  The 
proper  remedial  indication  for  foreign  bodies  in  the  antrum,  is 
their  removal.  When  insects  are  discovered  here,  injections  of 
oil  and  tepid  water  are  recommended.  This  constitutes  all  the 
treatment  necessary  to  be  employed  in  cases  of  this  kind. 


PART    SIXTH. 


MECHANICAL   DENTISTRY 


PART    SIXTH. 


MECHANICAL  DENTISTRY. 

By  mechanical  dentistry  is  meant  the  art  of  constructing  and 
adapting — 1.  Appliances  for  the  correction  of  Irregularity  in 
the  arrangement  of  the  natural  teeth ;  2.  Artificial  Teeth ;  3. 
Artificial  Palates.  As  the  various  (1)  appliances  employed  for 
the  correction  of  irregularity  of  the  teeth  have  already  been 
described,  it  will  not  be  necessary  to  refer  to  the  subject  again. 
In  treating  upon  this  part  of  our  subject,  we  shall,  for  the  pre- 
sent, confine  ourself  to  the  description  of  the  various  methods 
of  constructing  and  applying  (2)  artificial  teeth,  reserving  what 
we  may  have  to  say  upon  (3)  artificial  obturators  and  palates  for 
the  seventh  and  last  part  of  our  work. 

Before  entering  upon  a  description  of  the  method  of  proce- 
dure in  the  construction  of  artificial  substitutes  for  the  natural 
teeth,  and  the  manipulations  connected  therewith,  we  shall  offer 
a  few  general  remarks  on  the  subject  of  such  substitutes — the 
substances  of  which  they  are  composed ;  the  means  employed 
for  their  retention  in  the  mouth ;  and  the  surgical  treatment  re- 
quired preparatory  to  their  application. 


CHAPTER    FIRST. 
ARTIFICIAL  TEETH. 

Contributing  as  the  teeth  do  to  the  beauty  and  expression 
of  the  countenance;  to  correct  enunciation;  and,  through  the 
improved  facility  of  mastication,  to  the  health  of  the  whole  or- 
ganism— it  is  not  surprising  that  their  loss  should  be  considered 
a  serious  affliction,  and  that  art  should  be  called  upon  to  replace 
such  loss  with  artificial  substitutes.  So  great,  indeed,  is  the  lia- 
bility of  the  human  teeth  to  decay,  and  so  much  neglected  are 
the  means  of  their  preservation,  that  few  persons,  at  the  present 
day,  reach  even  adult  age  without  losing  one  or  more  of  these 
invaluable  organs.  Happily  for  suffering  humanity,  they  can 
now  be  replaced  with  artificial  substitutes  so  closely  resembling 
the  natural  organs,  as  to  be  readily  mistaken  for  them,  even  by 
critical  and  practiced  observers.  Although  there  is  a  perfection 
in  the  work  of  nature  that  can  never  be  equaled  by  art,  artifi- 
cial teeth  are  now  so  constructed  as  to  subserve,  at  least  to  a 
great  extent,  the  purposes  of  the  natural  organs.  When  pro- 
perly adjusted,  they  are  worn  without  the  slightest  discomfort; 
so  much  so,  in  many  cases,  that  the  patient,  after  they  have 
been  in  the  mouth  a  few  days,  is  scarcely  conscious  of  their 
presence. 

The  construction  and  insertion  of  artificial  teeth  is  an  opera- 
tion which,  though  acknowledged  to  be  of  great  importance,  and 
performed  by  every  one  having  any  pretension  to  a  knowledge 
of  dentistry,  is,  unfortunately,  but  little  understood  by  the  ma- 
jority of  practitioners.  The  mouth  is  often  irreparably  injured 
by  their  improper  application.  A  single  artificial  tooth,  badly 
inserted,  may  cause  the  destruction  of  the  two  adjacent  natural 
teeth,  or  those  to  which  the  artificial  appliance  is  secured ;  and 
if  the  deficiency  thus  occasioned  be  unskillfully  supplied,  it  may 
cause  the  loss  of  two  more;  in  this  way  all  the  teeth  of  the 
upper  jaw  are  sometimes  destroyed. 


ARTIFICIAL   TEETH.  ^593 

The  utility  of  artificial  teeth  depends  upon  their  being  properly 
constructed,  and  correctly  applied.  Nor  is  there  any  branch  of 
dental  practice  that  requires  more  skill  and  judgment,  or  more 
extensiA'e  and  varied  scientific  information.  A  knowledge  of  the 
anatomy  and  physiology  of  the  mouth,  of  its  various  pathological 
conditions,  and  of  its  therapeutical  indications  is  as  essential  to 
the  mechanical  as  to  the  operative  dentist ;  moreover  to  correct 
information  upon  these  subjects,  must  be  superadded  ability  to 
execute  with  the  nicest  skill  and  most  perfect  accuracy,  the  vari- 
ous pieces  of  mechanism  required  in  dental  prosthesis. 

There  are  difiiculties  connected  with  the  insertion  of  artificial 
teeth  which  none  but  an  experienced  dentist  has  any  idea  of. 
They  must  be  constructed  and  applied  in  such  a  manner,  that 
they  may  be  easily  removed  and  replaced  by  the  patient ;  at  the 
same  time  they  must  be  securely  fixed  in  the  mouth,  and  pro- 
ductive of  no  injury  to  the  parts  with  w4iich  they  are  in  relation. 
But  there  are  sometimes  others  equally  difficult  to  overcome,  for 
example :  the  loss  of  a  tooth  in  one  jaw,  is  generally  followed 
by  the  gradual  protrusion  of  its  antagonist  from  the  socket ;  so 
that  if  the  loss  of  the  former  be  rephaced  with  a  substitute  of 
•qual  size,  it  will  often  strike  against  the  latter  at  each  occlusion 
of  the  mouth,  and  prevent  the  other  teeth  from  coming  together. 
This  tendency  of  the  teeth  in  one  jaw  to  protrude,  is  always  in 
proportion  to  the  number  lost  in  the  other ;  and  if  not  soon 
counteracted  by  the  replacement  of  the  latter  with  artificial  sub- 
stitutes, it  often  gives  rise  to  difficulties  in  their  proper  applica- 
tion, requiring  no  little  ingenuity  and  tact  to  overcome. 

Notwithstanding  the  triumphs  of  Mechanical  Dentistry,  and 
the  high  state  of  excellence  to  which  it  has  arrived,  at  no  previ- 
ous time  was  there  ever  so  much  injury  inflicted,  and  suftering 
occasioned  by  artificial  teeth,  as  at  present — resulting  solely  from 
their  bad  construction  and  incorrect  application.  That  such 
should  be  the  case,  when  there  are  so  many  scientific  and  skillful 
dentists  in  every  city,  and  in  many  of  the  villages  of  the  coun- 
try, may  seem  strange,  but'  the  fact  is  nevertheless  undeniable. 
We  may  explain  it  in  part  by  the  very  rapidly  increasing  demand 
for  dental  services,  which  has  not  allowed  time  for  the  develop- 
ment of  intelligent  and  skilled  labor  either  of  head  or  hand ;  in 
part  also  by  the  universal  experience  that   all   new  professions 


594  ARTIFICIAL    TEETH. 

are  full  of  immature  and  crude  material.  But  these  explanations 
cannot  long  be  received  in  excuse  for  a  state  of  things  which 
ought  to  be  rapidly  disappearing — which  is  in  fact  giving  way 
under  the  combined  influence  of  our  colleges,  our  periodicals 
and  text-books,  the  teachings  and  example  of  our  eminent  prac- 
titioners and  the  more  appreciative  judgment  of  the  public. 

The  information  obtainable  from  works  on  mechanical  den- 
tistry, was  until  recently  exceedingly  limited ;  and  it  is  sur- 
prising, that  from  the  number  who  have  written  on  the  diseases 
and  loss  of  the  teeth,  this  subject  should  have  received  so  little 
attention.  Fauchard,  Bourdet,  Angermann,  Maury,  Delabarre, 
Koecker,  Lefoulon,  Brown  and  a  few  others,  were  all  who  had 
given  it  anything  more  than  a  passing  notice  ;  and  the  works  of 
but  few  of  these  writers  contain  anything  like  explicit  directions 
upon  the  subject.  Delabarre's  Mechanical  Dentistry  was,  at  the 
time  of  its  publication,  a  work  of  much  merit.  The  various 
methods  adopted  at  that  period,  for  the  construction  and  applica- 
tion of  artificial  teeth,  are  accurately  and  minutely  described, 
together  with  the  advantages  and  disadvantages  of  each.  But, 
however  perfect  the  work  may  then  have  been,  it  does  not  furnish 
the  information  required  upon  the  subject  at  the  present  day. 
And  still  more  deficient  in  correct  information  are  nearly  all  the 
other  French  works. 

Among  the  English  writers,  Koecker  is  almost  the  only  one, 
except  Robinson,  a  more  recent  author,  who  has  described  cor- 
rectly the  principles  upon  which  artificial  teeth  should  be  applied. 
His  "  Essay  on  Artificial  Teeth,  Obturators  and  Palates,"  con- 
tains much  useful  and  valuable  information.  It  does  not,  how- 
ever, contain  a  description  of  the  manner  of  constructing  a 
dental  substitute,  preparatory  to  its  application ;  yet,  to  one 
capable  of  executing  the  various  manipulations  required  in  this 
department  of  practice,  it  is  very  serviceable.  Dr.  Koecker, 
perhaps,  thought  that  as  this  ability  can  only  be  acquired  by  a 
regular  apprenticeship,  a  more  minute  description  was  unneces- 
sary. There  are  many  practitioners,  however,  who,  although  m 
other  respects  competent,  have  not,  in  the  mechanical  depart- 
ment, enjoyed  this  advantage,  and,  consequently,  it  is  to  be  re- 
gretted, that  he  has  not  entered  more  into  detail  upon  the  subject. 
But  most  of  the  deficiencies  that  exist  in  the  last  named  work, 


f 


ARTIFICIAL    TEETH.  595 

were  supplied  up  to  1844,  by  Dr.  Solyman  Brown,  in  his  series 
of  papers  on  Mechanical  Dentistry,  published  in  the  American 
Journal  of  Dental  Science.  These  papers  were  illustrated  with 
numerous  cuts,  and  constituted  the  best  treatise  upon  the  subject 
that  had  appeared  up  to  the  time  of  their  publication.  But 
numerous  and  important  improvements  have  subsequently  been 
made  in  this  department  of  practice,  all  of  which  we  propose  to 
give  a  brief  description  of  in  their  proper  place. 

The  only  treatises  upon  Mechanical  Dentistry,  published  in 
book  form,  in  this  country,  since  the  papers  of  Dr.  Brown,  have 
been  this  Division  of  our  own  work  and  the  Treatise  of  Professor 
G.  Richardson.  In  the  dental  periodicals  of  the  past  twelve  years 
will  be  found  many  carefully  prepared  papers  from  the  pen  of 
Professor  Austen.  These  journals  elsewhere  offer  a  vast  amount 
of  information,  very  valuable  to  the  practitioner  who  has  the 
ability  to  select  with  judgment.  They  give  also  an  instructive 
view  of  the  rapid  progress  made  in  dental  art,  and  teach  the 
necessity  of  being  constantly  alive  to  the  improvements,  real  or 
fancied,  which  are  almost  daily  proposed. 

We  shall  enumerate  some  of  the  different  kinds  of  dental  sub- 
stitutes that  have  been  employed  since  the  commencement  of  the 
present  century.  We  shall  also  notice  briefly,  the  principal 
methods  that  have  been  adopted  in  their  application,  before  en- 
tering upon  a  minute  description  of  those  practiced  at  the  present 
time.  Great  improvements  have  been  made  in  dental  prosthe- 
sis since  the  publication  of  the  first  edition  of  this  work.  In  fact 
no  science  or  art,  except  Chemistry,  has  been  so  eminently  pro- 
gressive during  the  last  twenty  years  as  Mechanical  Dentistry. 


CHAPTER    SECOND. 
SUBSTANCES  EMPLOYED  AS  DENTAL  SUBSTITUTES. 

There  are  two  qualities  which  it  is  highly  important  that 
dental  substitutes  should  possess.  They  should  be  durable  in 
their  nature ;  and  in  their  appearance  should  resemble  the  natu- 
ral organs  which  they  replace,  or  with  which  they  have  often 
to  be  associated. 

The  kinds  of  teeth  that  have  been  employed,  since  1830,  are : 

1.  Human  teeth, 

2.  Teeth  of  neat  cattle,  sheep,  &c. 

3.  Teeth  carved  from  the  ivory  of  the  elephant's  tusk,  and 
from  the  tooth  of  the  hippopotamus. 

4.  Porcelain  teeth,  called  also  indestructible  teeth. 

HUMAN  TEETH. 

As  regards  appearance,  which  in  a  dental  substitute  is  an  im- 
portant consideration,  human  teeth  are  preferable  to  any  other ; 
when  used  for  this  purpose,  they  should  be  of  the  same  class  as 
those,  the  loss  of  which  they  are  to  replace.  The  crowns  only 
are  employed,  and  if  well  selected,  and  skillfully  adjusted,  the 
artificial  connection  with  the  alveolar  ridge  cannot  easily  be  de- 
tected. 

The  durability  of  these  teeth  when  thus  employed,  depends 
upon  the  density  of  their  texture,  the  soundness  of  their  enamel, 
and  the  condition  of  the  mouth  in  which  they  are  placed.  If 
they  are  of  a  dense  texture,  with  sound  and  perfect  enamel,  and 
are  placed  in  a  healthy  mouth,  they  will  last  from  eight  to  twelve 
years  or  even  longer.  The  difficulty,  however,  of  procuring  these 
teeth,  is  generally  so  great,  that  it  is  seldom  that  such  as  we 
have  described,  can  be  obtained ;  and  even  when  they  can,  the 
mouth  in  half  the  cases  in  which  artificial  teeth  are  placed,  is  not 
in  a  healthy  condition  ;  its  secretions  are  often  so  vitiated  and  of 
so  corrosive  a  nature,  that  they  destroy  them  in  less  than  four 
years.  We  have  even  known  them  to  be  destroyed  by  caries  in 
two,  and  in  one  case  in  fifteen  months. 


TEETH    OF    CATTLE.  597 

A  liuman  tooth,  artificially  applied,  is  more  liable  to  decay 
than  one  of  equal  density  having  a  vital  connection  with  the 
general  system,  for  the  reason,  that  its  dentinal  structure  is 
more  exposed  to  the  action  of  deleterious  chemical  agents.  Yet 
of  all  the  animal  substances  employed  for  this  purpose,  human 
teeth  are  unquestionably  the  best.  They  are  harder  than  bone, 
and  being  more  perfectly  protected  by  enamel,  are  consequently 
more  capable  of  resisting  the  action  of  corrosive  agents. 

Many  object  to  having  human  teeth  placed  in  their  mouth, 
under  the  belief  that  infectious  diseases  may  be  communicated 
by  them.  There  is  no  good  foundation  for  such  fear,  because 
the  purifying  process  to  which  they  are  previously  submitted, 
precludes  the  possibility  of  the  communication  of  disease.  When 
the  practice  of  transplanting  teeth  was  in  vogue,  occurrences  of 
this  sort  were  not  unfrequent ;  but  since  that  has  been  discon- 
tinued, these  have  never  happened.  Still,  the  prejudices  of  some 
against  human  teeth  are  so  strong,  that  it  is  impossible  to  over- 
come them.  This  feeling,  the  difficulty  of  procuring  them,  the 
high  price  they  command,  and  their  want  of  durability  have 
gradually  led  to  their  entire  disuse :  which  is  scarcely  to  be  re- 
gretted, now  that  art  can  produce  in  porcelain  such  accurate 
imitations  of  nature.  The  only  cases  in  which  we  might  feel 
called  upon  to  insert  natural  teeth  is  when  any  of  the  twelve 
front  teeth  become  loosened  from  periosteal  disease  and  drop 
from  their  sockets  while  yet  perfectly  free  from  caries.  These 
teeth  themselves  may  often  be  adjusted  to  a  plate  so  as  to  pre- 
sent an  exceedingly  natural  appearance. 

TEETH  OF  CATTLE. 

Of  the  various  kinds  of  natural  teeth  employed  for  dental 
substitutes,  those  of  neat  cattle,  are,  perhaps,  after  human  teeth, 
the  best.  By  slightly  altering  their  shape,  they  may  be  made 
to  resemble  the  incisors  of  some  persons ;  but  a  configuration 
similar  to  the  cuspids  cannot  be  given  to  them,  and  in  a  majority 
of  cases  they  are  too  white  and  glossy  to  match  very  closely  the 
human  teeth.  The  contrast,  therefore,  which  they  form  with 
the  natural  organs  should  constitute,  were  they  in  all  other  re- 
spects suitable,  a  very  serious  objection  to  their  use.  This  imi- 
tation of  nature  has  been  too  much  disregarded,  both  by  dentists 


598  IVORY    AND    HIPPOPOTAMUS    TEETH. 

and  patients.  Indeed,  many  of  those  who  need  artificial  teeth, 
wish  to  have  them  as  white  and  brilliant  as  possible,  and  the 
practitioner  lacks  either  the  decision  or  the  judgment  to  refuse 
compliance  with  a  practice,  which  destroys  all  that  beauty  and 
fitness  which  it  is  the  aim  of  dental  aesthetics  to  cultivate. 

But  there  are  other  objections  to  the  use  of  these  teeth.  In 
the  first  place  they  are  only  covered  anteriorly  with  enamel ;  in 
the  second,  their  dentinal  structure  is  less  dense  than  that  of 
human  teeth,  and  consequently  they  are  more  easily  acted  on  by 
chemical  agents.  They  are,  therefore,  less  durable,  seldom  last- 
ing more  than  from  two  to  four  years.  Another  objection  to 
their  use  is,  they  can  be  employed  in  only  the  very  few  cases 
where  short  teeth  are  required,  owing  to  the  large  size  of  their 
nerve  cavities.  If  cut  down  to  the  proper  size  artificially,  these 
cavities  are  apt  to  be  exposed ;  and  if  filled  up  by  ossific  deposit 
while  in  the  mouth  of  the  animal,  they  are  by  that  time  worn 
down  too  short  to  be  of  use  except  when  very  short  teeth  are 
required.  It  is  seldom,  therefore,  that  they  can  be  advantage- 
ously used  as  substitutes  for  human  teeth. 

IVORY  OF  THE  ELEPHANT  AND  HIPPOPOTAMUS. 

Artificial  teeth  made  from  the  ivory  of  the  tusk  both  of  the 
elephant  and  hippopotamus  have  been  sanctioned  by  usage  from 
the  earliest  periods  of  the  existence  of  this  branch  of  the  art. 
We  must  not  hence  conclude  that  it  has  been  approved  by  ex- 
perience ;  on  the  contrary,  of  all  the  substances  that  have  been 
used  for  this  purpose,  this  is  certainly  the  most  objectionable. 

The  ivory  of  the  elephant's  tusk  is  decidedly  more  permeable 
than  that  obtained  from  the  hippopotamus.  So  readily  does  it 
absorb  the  buccal  fluids  that,  in  three  or  four  hours  after  being 
placed  in  the  mouth,  it  becomes  completely  saturated  with  them. 
Consequently,  it  is  not  only  liable  to  chemical  changes,  but  the 
absorbed  secretions  undergo  decomposition  ;  and  when  several 
teeth,  formed  from  it,  are  worn,  they  affect  the  breath  to  such  a 
degree  as  to  render  it  exceedingly  off'ensive.  Again  on  account 
of  its  softness,  teeth  are  easily  shaped  from  it ;  but  not  being 
covered  with  enamel,  they  soon  become  dark,  and  give  to  the 
mouth  a  repulsive  appearance.     Fortunately,  however,  in  the 


PORCELAIN   TEETH.  599 

United  States,  elephant's  ivory  is  rarely  used,  either  as  a  basis 
for  teeth  or  for  the  teeth  themselves. 

The  ivory  of  the  tusk  of  the  hippopotamus  is  much  firmer  in 
its  texture  than  that  obtained  from  the  elephant ;  being  covered 
with  a  hard,  thick  enamel,  teeth  may  be  cut  from  it,  which,  at 
first,  very  closely  resemble  the  natural  organs.  There  is,  how- 
ever, a  peculiar  animation  about  human  teeth,  which  those  made 
from  this  substance  do  not  possess :  moreover  they  soon  change 
their  color,  assuming  first  a  yellow  and  then  a  dingy  bluish  hue. 
They  are,  also,  like  elephant  ivory,  very  liable  to  decay.  We 
have  in  our  possession  a  number  of  blocks  of  this  sort,  some  of 
which  are  nearly  half  destroyed. 

But  the  same  objection  lies  against  teeth  made  from  the  hippo- 
potamus ivory,  which,  even  were  there  no  other,  would  be  suffi- 
cient to  condemn  its  use.  Like  those  formed  from  elephant 
ivory,  they  give  to  the  air  returned  from  the  lungs,  an  offensive 
odor,  which  cannot  be  corrected  or  prevented.  They  may  be 
washed  half  a  dozen  times  a  day,  and  taken  out  and  cleansed 
again  at  night,  but  it  will  still  be  perceptible ;  and,  although  it 
may  be  worse  in  some  mouths  than  others,  no  one  who  wears  teeth 
made  of  this  substance  can  be  entirely  free  from  it. 

PORCELAIN  OR  INCORRUPTIBLE  TEETH. 

The  manufacture  of  porcelain  teeth  did  not  for  a  long  time 
promise  to  be  of  much  advantage  to  dentistry.  But  by  the  in- 
genuity and  indefatigable  exertions  of  a  few,  they  have  within 
the  last  thirty  years,  been  brought  to  such  perfection  as  almost 
to  supersede  any  other  kind  of  artificial  teeth. 

The  French,  with  whom  the  invention  of  these  teeth  origina- 
ted, encouraged  their  manufacture  by  favorable  notices ;  and  the 
rewards  offered  by  some  of  the  learned  and  scientific  societies  of 
Paris  contributed  much  to  bring  it  to  perfection.  They  were 
still,  however,  deficient  in  so  many  particulars,  that  they  received 
the  approbation  of  very  few  of  the  profession,  and  then  only  in 
some  special  cases.  It  is  principally  to  American  dentists  that 
we  are  indebted  for  that  which  the  French  so  long  labored  in  vain 
to  accomplish. 

A  want  of  resemblance  to  the  natural  organs,  in  color,  trans- 
lucency,  and  animation,  was  the  great  objection  urged  against 


coo  PORCELAIN    TEETH. 

porcelain  teeth  ;  and,  had  not  this  been  obviated,  it  ^oiild  have 
constituted  an  insuperable  objection  to  their  use.  Until  1833, 
all  that  vere  manufactured  had  a  dead  opaque  appearance,  which 
rendered  them  easy  of  detection,  -when  placed  alongside  of  the 
natural  teeth,  and  gave  to  the  mouth  a  sickly  aspect.  But  so 
great  have  been  the  improvements  in  their  manufacture,  that 
few  can  now  distinguish  any  very  marked  difference  between 
them  and  the  natural  teeth. 

The  advantages  Avhich  mineral  teeth  possess  over  every  sort  of 
animal  substance,  are  numerous.  They  can  be  more  readily  se- 
cured to  the  plate,  and  are  worn  with  greater  convenience.  They 
do  not  absorb  the  secretions,  and,  consequently,  when  proper  at- 
tention is  paid  to  their  cleanliness,  they  do  not  contaminate  the 
breath,  or  become  in  any  way  offensive.  Their  color  never 
changes.  They  are  not  acted  on  by  the  chemical  agents  found 
in  the  mouth,  and  hence  the  name  incorruptible,  which  has  been 
given  them. 

The  objections  that  have  been  urged  to  the  use  of  porcelain 
teeth — such  as,  want  of  congeniality  between  them  and  the 
mouth,  their  better  conducting  power,  and  their  consequent 
greater  liabilit}'  to  the  action  of  heat  and  cold — have  so  little 
foundation,  that,  when  compared  with  the  advantages  they  con- 
fessedly possess,  they  must  be  regarded  as  unworthy  of  consider- 
ation. The  vast  extension  of  mechanical  practice  is  due,  more 
than  to  any  other  one  cause,  to  these  improvements  in  the  manu- 
facture of  porcelain  teeth, — improvements  essentially  American, 
and  so  important  as  fairly  to  justify  a  little  of  that  boasting 
spirit  which,  transplanted  from  the  mother  country,  has  attained 
such  luxuriant  growth  in  American  soil. 

The  beautifully  exact  imitation  of  the  varying  shades  of  the 
natural  gum,  which  as  yet  has  been  found  possible  only  in 
porcelain,  would  of  itself  give  to  this  material  a  claim  over 
every  other.  All  attempts  to  color  ivory  have  failed  to  produce 
any  permanent  results.  More  recent  experiments  in  the  several 
vulcanizable  materials  have  thus  far  given  opaque  and  lifeless 
colors,  which  no  stretch  of  the  imagination  can  compare  with  the 
natural  gum.  When  a  material  shall  have  been  discovered  pos- 
sessing the  valuable  properties  of  the  vulcanite,  combined  with 
the  beauty  of  a  porcelain  artificial  gum,  dental  prosthesis  will 
have  nearly  reached  perfection. 


CHAPTER    THIRD. 

DIFFERENT  METHODS  OF  INSERTING  ARTIFICIAL 
TEETH. 

The  methods  of  retaining  artificial  teeth  in  place  are — first, 
by  pivoting  to  the  natural  roots;  second,  by  attaching  to  metallic 
or  other  kind  of  base-plate,  secured  either  by,  1,  clasps,  2,  spiral 
springs,  or  3,  atmospheric  pressure.  The  peculiar  advantages 
of  each  of  these  methods  we  shall  now  proceed  to  point  out,  and 
the  cases  to  which  they  are  particularly  applicable. 

ARTIFICIAL  TEETH  PLACED  ON  NATURAL  ROOTS. 

This  method  of  securing  artificial  teeth,  Avas,  until  recently, 
on  account  of  its  simplicity,  more  extensively  practiced  than 
any  other;  and,  under  favorable  circumstances,  is,  unquestion- 
ably, one  of  the  best  that  can  be  adopted.  If  the  roots  on  which 
they  are  placed  be  sound  and  healthy,  and  the  back  pait  of  the 
jaws  supplied  with  natural  teeth,  so  as  to  prevent  those  with 
which  the  artificial  antagonize  from  striking  them  too  directly, 
they  will  subserve  the  purposes  of  the  natural  organs  more  per- 
fectly than  any  other  description  of  dental  substitute,  and  can 
he  made  to  present  an  appearance  so  natural  as  to  escape  detec- 
tion upon  the  closest  scrutiny.  If  properly  fitted  and  secured, 
not  only  is  their  connection  with  the  natural  roots  not  easily 
detected,  but  they  may  render  valuable  service  for  many  years. 
The  incisors  and  cuspids  of  the  upper  jaw  are  the  only  teeth 
which  it  is  proper  to  replace  in  this  way. 

The  insertion  of  an  artificial  tooth  on  a  diseased  root,  or  on  a 
root  having  a  diseased  socket,  is  almost  always  followed  by 
injurious  consequences.  The  morbid  action  already  existing  in 
the  root,  or  its  socket,  is  aggravated  by  the  operation,  and  often 
caused  to  extend  to  the  contiguous  parts,  and  occasionally  even 
to  the  whole  mouth.  Even  in  a  healthy  root,  it  is  not  always 
39 


602  TEETH    SECURED    BY    PIVOT. 

proper  to  apply  a  tooth  immediately  after  having  prepared  the 
root.  If  any  irritation  is  produced  by  this  preparatory  process, 
the  tooth  should  not  be  inserted  until  it  has  wholly  subsided. 
The  neglect  of  this  precaution  not  unfrequently  gives  rise  to 
inflammation  of  the  alveolo-dental  periosteum  and  to  alveolar 
abscess. 

Although  this  method  of  securing  artificial  teeth  has  received 
the  sanction  of  the  most  eminent  dental  practitioners,  and  is, 
perhaps,  the  best  that  can  be  adopted  for  replacing  the  loss  of 
the  six  upper  front  teeth  ;  yet,  on  account  of  the  facility  with 
Avhich  the  operation  is  performed,  it  is  often  resorted  to  under 
the  most  unfavorable  circumstances;  in  consequence  of  which, 
the  method  has  been  undeservedly  brought  into  discredit.  Apart 
from  the  proneness  of  operators  to  resort  to  this  method  Avhen 
its  adoption  is  unjustifiable,  we  may  name  two  objections  to  the 
use  of  pivot  teeth,  as  ordinarily  prepared  and  inserted.  First, 
the  diflSculty  of  preventing  the  presence  of  secretions  between  the 
crown  and  root,  which  make  the  breath  ofi'ensive  and  cause  the 
root  gradually  to  decay.  Secondly,  the  more  or  less  rapid  en- 
largement of  the  canal  requiring  frequent  replacement  and  the 
ultimate  loss  of  the  fang. 

The  efforts  of  the  economy  for  the  expulsion  of  the  roots  of 
the  bicuspid  and  molar  teeth,  after  the  destruction  of  their 
lining  membrane,  are  rarely  exhibited  in  the  case  of  roots  of 
teeth  occupying  the  anterior  part  of  the  mouth.  This  circum- 
stance has  led  us  to  believe  that  the  roots  of  these  teeth  receive 
a  greater  amount  of  vitality  from  their  investing  membrane  than 
do  the  roots  of  those  situated  farther  back  in  the  mouth ;  and 
that  the  amount  of  living  principle  thus  supplied  is  sufficient  to 
prevent  them  from  becoming  manifestly  obnoxious  to  their 
sockets. 

Another  explanation  assumes  the  equal  vitality  of  all  the 
roots,  and  attributes  the  persistence  of  front  fangs,  upon  which 
a  crown  has  been  placed,  to  the  continuance  of  that  pressure  to 
which  it  was  subject  so  long  as  it  had  its  natural  crown.  It  is 
asserted,  in  maintenance  of  this  view,  that  front  roots,  left  to 
themselves,  Avill  disappear  in  the  same  manner  as  bicuspid  and 
molar  roots,  and  that  the  latter  may  be  retained,  if  an  artifi- 
cial crown  (attached  to  a  plate)  is  set  upon  them;  also,  that  the 


TEETH  SECURED  BY  CLASPS.  603 

process  of  expulsion  is  analogous  to  that  by  which  a  tooth  is 
elongated,  which  has  lost  its  antagonist. 

It  is  well  known  that  a  dead  root  is  always  productive  of  in- 
jury to  the  surrounding  parts,  and  that  nature  calls  into  action 
certain  agencies  for  its  expulsion.  Therefore,  attaching  a  tooth 
to  a  completely  dead  root,  is  manifestly  improper;  but  the  fangs 
of  the  front  teeth  are  rarely  entirely  deprived  of  vitality,  and 
lience,  after  the  destruction  of  their  lining  membrane,  they  often 
remain  ten,  fifteen,  and  sometimes  twenty  years,  without  very 
obviously  affecting  the  adjacent  parts. 

The  manner  of  preparing  a  root  and  inserting  a  tooth  upon  it 
will  hereafter  be  described. 


ARTIFICIAL  TEETH  SECURED  BY  CLASPS. 

This  method  of  inserting  artificial  teeth,  first  introduced  by 
the  late  Dr.  James  Gardette,  of  Philadelphia,  is,  perhaps,  in  fa- 
vorable cases,  one  of  the  firmest  and  most  secure  that  can  be 
adopted.  By  this  means,  the  loss  of  a  single  tooth,  or  of  seve- 
ral teeth,  in  either  or  both  jaws,  may  be  supplied.  A  plate  may 
ha  so  fitted  to  a  space  in  the  dental  circle,  and  secured  with 
clasps  to  other  teeth,  as  to  afibrd  a  firm  support  to  six,  eight, 
ten,  or  even  twelve  artificial  teeth. 

Teeth  applied  in  this  way,  when  properly  constructed,  will 
last  for  several  years,  and  sometimes  during  the  life  of  the  indi- 
vidual. But  it  is  essential  to  their  durability,  that  they  should 
be  correctly  arranged,  accurately  fitted,  and  substantially  se- 
cured to  the  plate;  that  the  plate  itself  be  properly  adapted  to 
the  gums,  and  the  clasps  attached  with  utmost  accuracy  to  teeth 
firmly  fixed  in  their  sockets. 

Gold  is  the  best  metal  that  can  be  employed  for  the  plate  and 
clasps.  For  the  former,  the  gold  should  be  from  twenty  to 
twenty-one  carats  fine,  and  from  eighteen  to  nineteen  for  the 
latter.  If  gold  of  an  inferior  quality  is  used,  it  will  be  liable  to 
be  acted  on  by  the  secretions  of  the  mouth.  Platina  perfectly 
resists  the  action  of  these  secretions,  and  would,  perhaps,  an- 
swer the  purpose  as  well  as  gold,  were  it  not  for  its  softness  and 
pliancy :  in  full  cases,  and  in  some  partial  cases,  the  shape  of 
the  plate  may,  more  or  less,  overcome  this  difficulty,  especially 


604  TEETH    WITH    SPIRAL    SPRINGS. 

when,   as  in  the  continuous  gum  work,  stiffened  by  other  ma- 
terials. 

The  plate  should  be  thick  enongh  to  afford  the  necessary  sup- 
port to  the  teeth  ;  but  not  so  thick  as  to  be  clumsy  or  inconve- 
nient from  its  weight.  The  clasps  generally  require  to  be  about 
one-third  or  one-half  thicker  than  the  plate,  and  sometimes 
double  the  thickness.  The  gold  used  for  this  purpose  is  some- 
times prepared  in  the  form  of  half  round  wire ;  but,  in  the  ma- 
jority of  cases,  it  is  preferable  to  have  it  flat,  as  such  clasps 
afford  a  firmer  and  more  secure  support  to  artificial  teeth  than 
those  Avhich  are  half  round;  they  also  occasion  less  inconve- 
nience to  the  patient,  and  are  productive  of  less  injury  to  the 
teeth  to  which  they  are  attached. 

Artificial  teeth,  applied  in  this  way,  may  be  worn  with  great 
comfort,  and  can  be  taken  out  and  replaced,  at  the  pleasure  of 
the  person  wearing  them.  It  is  important  that  they  should  be 
very  frequently  cleansed,  to  prevent  the  secretions  of  the  mouth 
that  get  between  the  plate  and  gums,  and  between  the  clasps  and 
teeth  ;  which  becoming  vitiated  may  irritate  the  soft  parts,  and 
corrode  the  teeth  and  taint  the  breath.  This  precaution  should, 
on  no  account,  be  neglected.  Great  care,  therefore,  should  be 
taken  to  fit  the  clasps  in  such  a  manner  as  will  admit  of  the  easy 
removal  and  replacement  of  the  piece,  and,  also,  that  they  may 
not  exert  any  undue  pressure  upon  the  teeth  to  which  they  are 
applied.  If  the  clasp,  in  consequence  of  inaccurate  adjustment 
strains  the  position  of  the  tooth  in  its  socket,  it  may  excite  in- 
flammation in  the  alveolo-dental  periosteum,  and  the  gradual 
destruction  of  the  socket  will  follow  as  a  natural  consequence. 
Also,  if  the  clasp  press  too  closely  upon  the  neck  of  tlie  tooth, 
it  may  develop  a  morbid  sensibility  in  the  cementum,  causing 
great  annoyance  and  possibly  exciting  inflammation  and  alveolar 
absorption  or  loosening  of  the  tooth. 

ARTIFICIAL  TEETH  WITH  SPIRAL  SPRINGS. 

The  only  difference  between  the  method  last  noticed,  of  ap- 
plying artificial  teeth,  and  the  one  now  to  be  considered,  consists 
in  the  manner  of  confining  them  in  the  mouth.  The  former  is 
applicable  in  cases  where  there  are  other  teeth  in  the  mouth  to 


TEETH    RETAINED    BY    ATMOSPHEKIC    PRESSURE.  605 

which  clasps  may  be  applied  :  the  latter  is  designed  for  confining 
a  whole  set,  or  part  of  a  set,  where  neither  clasps,  nor  anv  other 
means,  can  be  successfully  employed  for  their  retention,  and  pro- 
vided a  piece  is  required  in  the  lower  jaw,  to  which  one  end  of 
the  springs  may  be  secured. 

When  plates  with  spiral  springs  are  used,  the  teeth  are  at- 
tached to  them  in  the  same  manner  as  when  clasps  arc  employed  ; 
but  instead  of  being  fastened  in  the  mouth  to  other  teeth,  they 
are  kept  in  place  by  means  of  the  spiral  springs,  one  on  each 
side  of  the  artificial  dentures  between  them  and  the  cheeks,  pass- 
ing from  the  upper  piece  to  the  lower. 

Spiral  springs  were  formerly  much  used,  and  although  various 
other  kinds  of  springs  have  been  used,  none  seem  to  answer  the 
jiurpose  as  well  as  these.  AVhen  they  are  of  the  right  size,  and 
attached  in  a  proper  manner,  they  afford  a  very  sure  and  con- 
venient support.  They  exert  a  constant  pressure  upon  the  arti- 
ficial pieces,  whether  the  mouth  is  opened  or  closed.  They  do 
not  interfere  with  the  motions  of  the  jaw,  and,  although  they 
may  at  first  seem  awkward,  a  person  will  soon  become  so  accus- 
tomed to  them,  as  to  be  almost  unconscious  of  their  presence. 

Successive  improvements  in  the  process  of  adapting  the  plate 
to  the  mouth  have  gradually  lessened  the  number  of  cases  in 
which  spiral  springs  are  thought  necessary.  It  is  now  rare  to 
meet  with  a  case  in  which  they  are  absolutely  essential  for  the 
permanent  retention  of  the  piece ;  but  occasional  use  is  made  of 
them  for  the  temporary  retention  of  a  piece  made  soon  after  ex- 
traction, in  which  the  plate  is  designedly  made  more  even  than 
the  irregular  alveolar  border  :  which  plate  cannot  of  course  fit  the 
mouth  until  the  inequalities  of  the  gum  have  yielded  to  the  pres- 
sure of  the  plate. 

TEETH  RETAINED  BY  ATMOSPHERIC  PRESSURE. 

The  method  last  described,  of  confining  artificial  teeth  in  the 
mouth,  is  often  inapplicable,  inefficient  and  troublesome,  espe- 
cially for  the  upper  jaw  ;  in  such  cases,  the  atmospheric  pressure, 
or  suction  method,  is  very  valuable.  It  was,  for  a  long  time, 
thought  to  be  applicable  only  for  an  entire  upper  set,  because  it 
was  supposed  that  a  plate  sufficiently  large  to  afford  the  neces- 


606  TEETH    RETAINED    BY   ATMOSPHERIC    PRESSURE. 

sary  amount  of  surface  for  the  atmosphere  to  act  upon,  could  not 
be  furnished  by  a  piece  containing  a  smaller  number  of  teeth. 
Experience,  however,  has  proven  this  opinion  to  be  incorrect. 
A  single  tooth  may  be  mounted  upon  a  plate  presenting  a  surface 
large  enough  for  the  atmosphere  to  act  upon  for  its  retention  in 
the  mouth  ;  but,  when  only  a  partial  upper  set  is  required,  it  is 
often  more  advisable  to  secure  the  piece  by  means  of  clasps. 
For  a  like  reason,  it  was  thought  that  the  narrowness  of  the  in- 
ferior alveolar  ridge  would  preclude  the  application  of  a  plate  to 
it  upon  this  principle,  and  in  this  opinion  the  author  participated  ; 
but  he  has  succeeded  so  perfectly  in  confining  lower  pieces  by 
this  means,  that  he  now  never  finds  it  necessary  to  employ  spiral 
springs  for  their  retention. 

The  principle  upon  which  this  plan  is  founded,  may  be  simply 
illustrated  by  taking  two  small  blocks  of  marble  or  glass,  the  flat 
surfaces  of  w-hich  accurately  fit  each  other.     If  now  the  air  be- 
tween them  is  replaced  by  water,  the  atmospheric  pressure  upon 
their  external  surfaces,  will  enable  a  person  to  raise  the  under 
block,  by  lifting  the  upper.      Upon  the  same  principle,  a  gold 
plate,  or  any  other  substance,  impervious  to  the  atmosphere,  and 
perfectly  adapted  to  the  gums,  may  be  made  to  adhere  to  them. 
The  firmness  of  the  adhesion  of  the  plate  or  base  to  the  gums 
depends  on  the  accuracy  of  its  adaptation.     If  this  is  perfect. 
it  will  adhere  with  great  tenacity  ;  but  if  the  plate  is  badly  fitted, 
or  becomes  warped  in  soldering  on  the  teeth,  its  retention  will 
often  be  attended  with  difficulty.     It  is  also  important  that  the 
teeth  should   be  so  arranged  and  antagonized,  that  they  shall 
strike  those  in  the  other  jaw  on  both  sides  at  the  same  instant. 
This  is  a  matter  that  should  never  be  overlooked,  for  if  they  meet 
on  one  side  before  they  come  together  on  the  other,  the  part  of 
the  plate  or  base  not  pressed  upon,  will  be  detached,  and  by 
admitting  the  air  between  it  and  the  gums,  will  cause  it  to  drop. 
The  application  of  artificial  teeth  on  this  principle,  has  been 
practiced  for  a  long  time.     Its  practicability  was  first  discovered 
by  the  late  Mr.  James  Gardette,  of  Philadelphia.     But  the  plates 
formerly  used,  were  ivory  instead  of  gold,  and  could  seldom  be 
fitted  with  sufiicient  accuracy  to  the  mouth  to  exclude  the  air; 
so  that,  in  fact,  it  could  hardly  be  said  that  they  were  retained 
by  its  pressure.     Unless  fitted  in  the  most  perfect  manner,  the 


TEETH    RETAINED    BY    ATMOSPHERIC    PRESSURE.  607 

piece  is  constantly  liuble  to  drop,  and  the  amount  of  substance 
necessary  to  leave  in  an  ivory  substitute,  renders  it  so  awkward 
and  clumsy,  that  a  set  of  teeth  mounted  upon  a  base  of  this  ma- 
terial can  seldom  be  worn  wMth  much  comfort  or  satisfaction  ; 
moreover,  ivory  absorbs  the  fluids  of  the  mouth  so  readily,  that 
after  being  worn  for  a  few  weeks  it  becomes  exceedingly  offensive. 

The  firmness  with  which  teeth,  applied  upon  this  principle,  can 
be  made  to  adhere  to  the  gums,  and  the  facility  with  which  they 
can  be  removed  and  replaced,  renders  them,  in  many  respects, 
more  desirable  than  those  fixed  in  the  mouth  with  clasps.  But, 
unless  judgment  and  proper  skill  are  exercised  in  the  construc- 
tion of  the  teeth,  a  total  failure  may  be  expected,  or  at  least, 
they  will  never  be  worn  with  satisfaction  and  advantage. 

There  were  few  writers,  at  the  time  of  the  publication  of  the 
first  edition  of  this  work,  who  had  even  adverted  to  this  mode  of 
applying  artificial  teeth.  Drs.  L.  S.  Parnily  and  Koecker  had 
each  bestowed  on  it  a  passing  notice.  The  former,  in  alluding 
to  the  subject,  thus  remarks  :  "  Where  the  teeth  are  mostly  gone 
in  both,  or  in  either  of  the  jaws,  the  method  is,  to  form  an  arti- 
ficial set,  by  first  taking  a  mould  of  the  risings  and  depressions 
of  every  point  along  the  surface  of  the  jaws,  and  then  making  a 
corresponding  artificial  socket  for  the  whole.  If  this  be  accu- 
rately fitted,  it  will,  in  most  cases,  retain  itself  sufiiciently  firm, 
))y  its  adhesion  to  the  gums,  for  every  purpose  of  speech  and 
mastication."* 

It  has  not,  until  recently,  been  thought  expedient  to  apply 
parts  of  sets  upon  this  principle ;  nor  did  we,  for  a  long  time, 
)>elieve  the  pressure  of  the  atmosphere  w'ould  give  to  a  lower  set, 
because  of  the  narrowness  of  the  alveolar  ridge  of  the  inferior 
maxilla,  sufiicient  stability  to  render  it  at  all  serviceable;  but 
experience  has  fully  demonstrated  its  practicability. 

Dr.  Koecker  tells  us,  that  he  has  "  been  completely  success- 
ful in  several  instances,  in  the  application  of  sets  for  the  upper 
jaw  in  this  manner  ;  they  should  be  made  either  with  a  gold  plate 
mounted  with  natural  or  artificial  teeth,  or  of  one  piece  of  hip- 
popotamus-tooth, "f  Having  already  stated  the  objections  that 
"xist  to  the  use  of  this  substance,  we  cannot  join  with  Dr.  K.  in 

*  Practical  Guide  to  the  Management  of  the  Teeth.  i>p.  138-31*. 
t  Koecker  on  Artificial  Teeth,  p.  92. 


608     TEETH  RETAINED  BY  ATMOSPHERIC  PRESSURE. 

its  recommendation.  At  the  time  when  we  first  substituted  the 
gold  plate  for  ivory,  we  had  not  seen  his  late  work  on  artifi- 
cial teeth,  and,  consequently  were  not  aware  that  the  use  of 
metal  for  a  base  had  ever  before  been  recommended. 

Modifications  of  the  atmospheric  pressure  principle  have  been 
made  since  1845,  by  constructing  the  plate  with  an  air  chamber  or 
cavity,  so  that  when  the  air  is  exhausted  from  between  it  and 
the  parts  against  which  it  is  placed,  a  more  or  less  complete 
vacuum  is  formed,  causing  it  to  adhere  when  first  introduced 
with  greater  tenacity  to  the  gums  than  a  base  fitted  without  such 
cavity.  This  modification  might  be  termed  an  improvement, 
were  it  not  that  its  introduction  has  become  so  unnecessarily 
general,  has  so  often  induced  a  diseased  condition  of  the  mucous 
membrane,  and  has  led  to  a  slovenly,  careless  method  of  swaging 
and  fitting  plates.  For  these  and  some  other  reasons,  Professor 
Austen  regards  its  introduction  as  a  positive  detriment,  at  the 
same  time  that  he  acknowledges  its  occasional  utility. 

Other  methods  have  been  resorted  to  for  the  retention  of  arti- 
fiicial  teeth,  but  as  they  have  long  since  been  abandoned,  a  de- 
scription of  them  is  rendered  unnecessary. 


CHAPTER    FOURTH. 

TREATMENT    OF    THE  MOUTH    PREPARATORY  TO   THE 
INSERTION  OF  ARTIFICIAL  TEETH. 

The  condition  of  the  mouth  is  not  sufficiently  regarded  in  the 
application  of  artificial  teeth,  and  to  the  neglect  of  this,  the  evil 
effects  that  so  often  result  from  their  use,  are  frequently  attribu- 
table. An  artificial  appliance,  no  matter  how  correct  it  may  be 
in  its  construction  and  in  the  mode  of  its  application,  cannot  be 
worn  with  impunity  in  a  diseased  mouth.  Of  this  fact,  every 
day's  experience  furnishes  the  most  abundant  proof.  Yet  there 
are  men  in  the  profession,  so  utterly  regardless  of  their  own 
reputation  and  of  the  consequences  to  their  patients,  as  wholly  to 
disregard  the  condition  of  the  mouth,  and  are  in  the  constant 
habit  of  applying  artificial  teeth  upon  diseased  roots  and  gums, 
or  before  the  curative  process,  after  the  extraction  of  the  natural 
teeth,  is  half  completed. 

The  dentist,  it  is  true,  may  not  always  be  to  blame  for  omit- 
ting to  employ  the  means  necessary  for  the  restoration  of  the 
mouth  to  health.  The  fault,  oftentimes,  is  with  the  patient. 
There  are  many,  who,  after  being  fully  informed  of  tlie  evil  effects 
which  much  of  necessity  result  from  such  injudicious  practice, 
still  insist  on  its  adoption.  But  the  dentist,  in  such  cases,  does 
wrong  to  yield  his  better  informed  judgment  to  the  caprice  or 
timidity  of  his  patient,  knowing,  as  he  should,  the  lasting,  per- 
nicious consequences  that  must  result  from  doing  so.  If  he  is 
not  permitted  to  carry  out  such  plan  of  treatment  as  may  be 
necessary  to  put  the  mouth  of  his  patient  in  a  healthy  condition, 
previously  to  the  application  of  artificial  teeth,  he  should  refuse 
to  render  his  services. 

Dr.  Koecker,  in  treating  upon  this  subject,  says,  "  There  is, 
perhaps,  not  one  case  in  a  hundred,  requiring  artificial  teeth,  in 
which  the  other  teeth  are  not  more  or  less  diseased,  and  tlic  gums 
and  alveoli,  also,  either  primarily  or  secondarily  affected.     The 


610       PREPARATORY  TREATMENT  OF  THE  MOUTH. 

mechanical  and  chemical  bearing  of  the  artificial  teeth,  even  if 
well  contrived  and  inserted  upon  such  diseased  structures,  natu- 
rally becomes  an  additional  aggravating  cause  of  disease  in  parts 
already  in  a  sufficient  state  of  excitement;  if,  however,  they  are 
not  well  constructed,  and  are  inserted  with  undue  means  or 
force,  or  held  by  too  great  or  undue  pressure,  or  by  ligatures  or 
other  pernicious  means  for  their  attachment,  the  morbid  effects 
are  still  more  aggravated,  and  a  general  state  of  inflammation 
in  the  gums  and  sockets,  and  particularly  in  the  periosteum, 
very  rapidly  follows.  The  patient,  moreover,  finds  it  impossible 
to  preserve  the  cleanliness  of  his  mouth ;  and  his  natural  teeth, 
as  well  as  the  artificial  apparatus,  in  combination  with  the  dis- 
eases of  the  structures,  become  a  source  of  pain  and  trouble; 
and  the  whole  mouth  is  rendered  highly  offensive  and  disgusting 
to  the  patient  himself,  as  Avell  as  to  others."* 

The  first  thing,  then,  claiming  the  attention  of  the  dentist, 
when  applied  to  for  artificial  teeth,  is  to  ascertain  the  condition 
of  the  gums  and  of  such  teeth  as  may  be  remaining  in  the  mouth. 
If  either  or  both  are  diseased,  he  should  at  once  institute  such 
treatment  as  the  circumstances  of  the  case  may  indicate ;  but  as 
this  has  been  described  in  a  preceding  chapter,  it  is  only  neces- 
sary now  to  refer  the  reader,  for  directions  upon  the  subject,  to 
what  is  there  said. 

When  artificial  teeth  are  to  be  secured  in  the  mouth  in  any 
other  Avay  than  by  pivoting  upon  the  roots,  sufficient  time  should 
elapse,  before  their  insertion,  for  the  completion  of  all  those 
changes  that  follow  the  treatment  which  is  usually  necessary  in 
such  cases;  otherwise,  instead  of  being  worn  with  comfort,  they 
will  be  a  source  of  constant  irritation.  If  they  are  applied  too 
soon,  they  will  lose  their  adaptation  to  the  gums.  We  have 
now  in  our  possession  a  number  of  parts  of  sets  which  had  been 
prematurely  applied;  the  changes  in  the  shape  of  the  parts  on 
which  they  rested  caused  them  to  press  so  unequally  on  the 
gums,  that  their  removal  became  absolutely  necessary  for  the 
relief  of  the  irritation  and  pain  they  occasioned.  The  persons 
from  whose  mouths  they  were  taken  assured  u--,  that  at  the  time 
of  their  application  they  fitted  very  accurately,  and  were  worn 
for  a  short  time  with  comfort. 

*  Koecker's  Essay  on  Artificial  Teeth,  pp.  27,  28. 


f 


PREPARATORY  TREATMENT  OF  THE  MOUTH.       611 

It  is  often  necessary  to  wait  from  eight  to  fifteen  months  after 
the  removal  of  the  natural  teeth,  for  the  completion  of  the 
changes  which  take  place  in  the  alveolar  ridge  after  extraction. 
In  the  meantime,  it  is  generally  necessary  to  supply  the  patient 
with  a  temporary  substitute,  as  comparatively  few  persons  are 
willing  to  remain  for  so  long  a  time  without.  Nor  on  some 
accounts  is  it  desirable  that  they  should ;  for  in  this  long  inter- 
val the  lips  lose  somewhat  their  natural  expression,  the  under 
jaw  forgets  its  natural  motion,  and  inclines  to  project.  The 
artificial  piece  or  pieces  feel  more  awkward  and  unmanngeable 
than  if  inserted  at  once;  they  also  interfere  more  with  the  articu- 
lation and  motions  of  the  tongue,  which  have  become  accustomed 
to  the  absence  of  the  teeth. 

Hence  the  insertion  of  artificial  pieces  may  become  advisable 
very  soon  after  extraction — the  interval  varying  from  hours,  or 
days  to  weeks,  or  months.  In  some  of  these  cases  the  piece  will 
have  to  be  remodeled  at  short  intervals;  in  other  cases,  the 
piece,  as  first  made,  continues  to  be  worn  for  many  years  with 
much  comfort.  It  is  not  easy  to  explain  these  differences. 
Much  depends  upon  the  nature  of  the  mucous  and  submucous 
tissues,  whether  hard  or  soft ;  and  much  also  upon  the  manner 
in  which  the  alveolar  ridge  changes.  It  may  take  place  rapidly, 
and  with  slight  regard  to  the  shape  of  the  plate;  in  which  case, 
the  patient  has  to  use  much  tact  in  retaining  the  piece  in  place. 
Or  it  may  take  place  slowly;  following,  as  it  is  apt  more  or  less 
to  do,  the  shape  of  the  plate :  in  Avhich  case  it  may  be  worn  with 
some  comfort,  or  even  with  great  satisfaction,  for  a  long  time. 

A  plate  made  immediately  after  extraction,  should  not  fit  the 
ridge  exactly;  but  allowance  should  be  made  for  the  rapid 
absorption  of  the  prominent  edges  of  the  alveoli.  Some  prac- 
titioners advise  the  anticipation  of  this  process  by  "paring 
down"  the  alveolar  ridge.  This  "bold  surgery"  has  its  advan- 
tages and  its  advocates.     We  think  it  an  uncalled  for  cruelty. 


CHAPTER    FIFTH. 

MANNER    OF    PRP]PAIIING    A    NATURAL    ROOT    AND 
SECURING   AN  ARTIFICIAL  CROWN  TO  IT. 


Previously  to  the  preparation  of  a  natural  root  for  the  re- 
ception of  an  artificial  tooth,  the  remaining  teeth  and  gums,  if 
diseased,  should  be  restored  to  health.  This  done,  such  portion 
of  the  crown,  as  may  not  have  been  previously  destroyed  by 
caries,  should  be  removed. 

The  usual  method  of  performing  this  part  of  the  operation 
when  much  of  the  crown  remains,  consists  in  cutting  the  tooth 
about  three  fourths  off  with  a  file  or  very  fine  saw,  (Fig.  167), 

Fig.  167. 


and  then  removing  it  with  a  pair  of  excising  forceps.  But  the 
forceps  should  not  be  applied  until  the  tooth  has  been  cut  with 
a  file  on  every  side,  nearly  to  the  pulp  cavity,  and  even  then 
great  care  is  necessary  to  prevent  jarring,  or  otherwise  injuring 
the  root.  When  too  large  a  portion  of  the  crown  is  dipt  off 
suddenly  with  excising  forceps,  the  concussion  is  often  so  great 
as  to  excite  inflammation  in  the  socket  of  the  tooth,  and  some- 
times to  shatter  the  root. 

When  excising  forceps  are  used  in  this  way,  they  should  be 
strong,  so  as  not  to  spring  under  the  pressure  of  the  hand,  with 

Fig.   168. 


cutting  edges  about  an  eighth  of  an  inch  wide,  (Fig.  168.)  But 
we  should  prefer,  where  a  large  part  of  the  crown  is  left,  to  re- 
move it  entirely  with  the  fine  saw.  Where  there  is  only  a  jagged 


MANNER    OF    SECURING    A    PIVOT    TOOTH.  613 

remnant  of  the  crown  left,  it  should  be  gradually  cut  away  by 
a  pair  of  cutting  forceps  made  as  light  as  possible,  with  a  sprint 
between  the  blades  of  the  handle  to  keep  them  apart.  The  cut- 
ting edges  may  be  shaped  as  in  the  ordinary  excising  forceps, 
(Fig.  168),  or  somewhat  like  the  beaks  of  Parmly's  duck-bill 
root  forceps,  represented  in 

Fig.   169. 


After  the  removal  of  the  remaining  portion  of  the  crown,  the 
nerve,  if  still  alive,  should  be  immediately  destroyed,  by  intro- 
ducing a  silver  or  untempered  steel  wire,  or  some  other  small 
sharp-pointed  instrument,  up  to  the  extremity  of  the  root,  giving 
it,  at  the  same  time,  a  quick  rotary  motion.  It  is  important  that 
the  instrument  used  for  this  purpose,  should  be  soft  and  yielding, 
otherwise,  any  sudden  motion  of  the  head  of  the  patient  might 
break  it  off  in  the  tooth.  Its  extremity  should  also  be  barbed  or 
bent  so  as  to  entangle  and  drag  out  the  nerve  when  withdrawn. 

Some  recommend  destroying  the  nerve  by  the  introduction  of 
a  hot  wire  into  the  canal  of  the  root,  but  as  this  is  very  liable  to 
produce  irritation  in  the  surrounding  tissues,  the  other  method 
is  preferable. 

The  nerve  having  been  destroyed,  the  remainder  of  the  opera- 
tion will  be  painless.  The  root  may  now  be  filed  off,  a  little  above 
the  free  edge  of  the  gum,  Avith  an  oval  or  half  round  file.  The 
file  should  be  new  and  sharp  so  as  to  cut  rapidly,  but  not  too 
coarse  lest  it  jar  the  root  too  much.  It  must  be  kept  cold  and 
clean  by  frequent  dipping  in  water.  The  exposed  extremity  of 
the  root,  after  having  been  thus  filed,  should  present  a  slightly 
arched  appearance,  corresponding  with  the  festooned  shape  of 
the  anterior  margin  of  the  gum. 

After  having  completed  this  part  of  the  operation,  the  natural 
canal  in  the  root  should  be  slightly  enlarged  with  a  burr- drill, 
or  a  broach  prepared  for  the  purpose.  A  slightly  projecting 
point  on  the  end  of  the  drill  will  serve  by  entering  the  canal  to 
guide  the  instrument,  which  must  be  held  steadily  in  one  direc- 


614  MANNER    OF    SECURING    A    PIVOT   TOOTH. 

tion.  The  canal  thus  formed  in  the  root  for  the  pivot  should 
never  exceed  the  sixteentii  part  of  an  inch  or  a  line  in  diameter, 
and  a  quarter  or  three  eighths  of  an  inch  in  length. 

If  from  any  peculiar  constitutional  susceptibility  there  is  reason 
to  apprehend  inflammation  of  the  alveolo-dental  membrane,  the 
insertion  of  the  tooth  may  be  delayed  a  few  days  for  the  subsi- 
dence of  any  irritation  which  may  have  been  occasioned  by  the 
preparation  of  the  root.  It  will  be  prudent  to  do  this  in  all 
cases,  although  it  rarely  happens  that  the  operation  is  followed 
by  any  unpleasant  effects,  unless  this  has  previously  lost  its 
vitality  by  the  spontaneous  disorganization  of  the  nervous  pulp. 
In  this  case,  an  outlet  may  be  made  by  cutting  a  groove  on  the 
side  of  the  pivot,  or  in  some  other  way,  for  the  escape  of  any 
matter  which  may  form  at  the  apex  of  the  root.  But  it  is  better 
in  such  cases  to  extract  the  root  unless  the  discharge  can  be  per- 
manently arrested.  Dr.  Maynard  believes  that  the  irritation  in 
most  cases,  arises  from  an  accumulation  of  acrid  matter  in  the 
upper  part  of  the  root ;  by  removing  which  and  by  filling  the 
natural  canal  above  the  terminus  of  the  pivot,  up  to  the  extremity, 
it  may  generally  be  prevented.     This  should  always  be  done. 

After  having  prepared  the  root,  an  artificial  crown  of  the  right 
shape,  color  and  size,  is  accurately  fitted  to  it.  It  should  touch 
every  part  of  the  filed  extremity  of  the  root,  and  be  made  to  rest 
firmly  upon  it,  to  give  security  of  support,  and  to  exclude  food 
and  other  substances  which  by  their  decay  will  give  rise  to  un- 
pleasant odors.  Care  must  also  be  used  to  have  the  tooth  placed 
in  exact  line  with  the  other  teeth,  not  inclining  unnaturally  to 
either  side,  and  not  so  long  as  to  touch  the  lower  teeth  when  the 
mouth  is  closed.  To  fit  the  crown  accurately  is  often  a  tedious 
process,  and  wearies  the  patient.  To  avoid  this,  an  impression 
of  the  space  may  be  taken,  and  the  crown  adapted  to  the  model, 
which  should  be  hardened  by  varnish  or  soluble-glass. 

The  canal  in  the  root,  and  that  in  the  artificial  crown,  should 
be  directly  opposite  to  each  other.  When  the  crown  of  a  natural 
tooth  is  used,  it  can  be  adapted  to  the  root  by  the  use  of  the 
file ;  the  proper  place  for  the  pivot  is  indicated  by  the  pulp 
cavity,  but  in  porcelain  teeth  the  hole  is  not  always  in  the  centre. 

In  selecting  a  suitable  artificial  pivot  tooth,  it  is  often  difficult 
to  find  the  several  requirements  of  length,  width,  color  and  posi- 
tion of  pivot  hole  just  as  required.     The  two  last  cannot  be 


MANNER    OF    SECURING    A    PIVOT    TOOTH. 


615 


Fig.  170. 


changed  but  the  two  first  may  often 
be  modified  by  the  corundum  wheel. 
If  the  color  cannot  be  exactly 
matched,  it  is  perhaps  better  to 
select  one  a  shade  darker  rather 
than  lighter. 

For  grinding  the  edge,  sides,  or 
base  of  the  tooth,  any  of  the  hand 
lathes  in  use  will  answer  very  well. 
Fig.  170  represents  one  where  the 
wheel,  either  of  stone  or  corundum, 
revolves  in  a  vessel  containing 
water.     Figs.    171    and    172    represent    very    convenient    and 

Fig.   171. 


useful  forms  of  the  hand  lathe.  The  foot  lathe  elsewhere 
described  is  best  suited  for  the  laboratory  ;  but,  for  such  grind- 
ing and  fitting  of  teeth  as  must  be  done  at  the  operating  chair,  a 
hand  lathe  will  be  found  very  convenient. 

Fig.  172. 


The  artificial  crown  may  be  secured  to  the  root  by  means  of 
a  pivot  made  of  wood  or  metal  ;  when  the  latter  is  employed, 
gold,  platina  or  their  alloys  are  to  be  preferred,  inasmuch  as  silver 
or  any  baser  metal  is  liable  to  be  oxidized  by  the  fluids  of  the 


616  MANNER    OF    SECURING    A    PIVOT    TOOTH. 

mouth.  If  wood  is  used,  it  should  be  of  the  best  quality  of  well 
seasoned  young  white  hickory,  as  this  possesses  greater  strength 
and  elasticity  than  any  other  that  can  be  procured  in  this  coun- 
try. After  being  reduced  to  near  the  size  of  the  orifice  of  the 
cavity  in  the  artificial  tooth,  it  should  be  forced  through  a  smooth 
hole,  of  the  proper  size,  in  a  piece  of  ivory,  bone,  steel,  or  some 
other  hard  substance,  for  the  purpose  of  compressing  its  fibres 
as  closely  together  as  possible.  Thus  prepared,  one  end  is  forced 
into  the  cavity  in  the  artificial  crown,  and  the  projecting  part 
cut  off"  about  a  quarter  or  three-eighths  of  an  inch  from  the 
tooth  according  to  the  depth  of  the  canal.  If  the  canals  in 
crown  and  root  are  equal  in  size,  the  pivot  is  ready  to  be  pressed 
into  place;  which  should  be  done  with  the  thumb  and  fore-finger, 
if  the  pivot  is  made  of  compressed  wood.  But  if  the  canals  difi'er 
in  size,  the  wood  must  be  compressed  to  the  size  of  the  larger 
and  then  trimmed  down  to  fit  the  smaller.  The  end  thus 
trimmed  should  require  more  force  for  its  introduction,  since  the 
compressed  wood  swells  most  from  moisture.  The  part  of  the 
pivot  going  into  the  root,  if  made  of  compressed  wood  should 
never  be  so  large  as  to  require  any  other  pressure  than  that 
which  can  be  applied  with  the  thumb  and  fore-finger ;  as  the 
swelling  of  the  wood  will  soon  render  it  sufficiently  tight  to  hold 
it  firmly  in  its  place,  and  if  too  tight  the  subsequent  swelling 
will  split  the  root.  The  practice  of  driving  a  pivot  up  with  a 
hammer,  or  by  very  strong  pressure  as  is  often  done,  is  a  bad 
one.  It  is  apt  to  cause  inflammation  and  suppuration  of  the 
soft  tissues  about  the  apex  of  the  root.  The  utmost  force  ad- 
missible, and  this  only  in  the  case  of  uncompressed  pivot  wood, 
is  somewhat  more  than  can  be  made  with  the  thumb  and  finger, 
applied  by  means  of  a  small  pine  stick  notched  at  the  end  to  re- 
ceive the  cutting  edge  of  the  tooth. 

It  is  important  that  the  pivot  should  exactly  equal  the  depth 

of  the  canal.     If  too  long,  the  crown  will  not  go  up  to  its  place ; 

if  too  short,  there  will  be  either  an    unnecessary 

weakening  of  the  root  or  the  crown  will  be  insecure. 

II         I 
JL     JL     A  small  piece  of  smooth  wire  or  knitting  needle  with 

W      Bj    a  sliding  collar  of  wood  or  gutta  percha  forms  a  sim- 
ple instrument  for  measuring  the  depth  of  the  canal 
in   the   root.     A   porcelain    tooth  with  a  wood  pivot   presents 
before  insertion  the  appearance  represented  in  Fig.  173. 


MANNER   OF    SECURING   A    PIVOT   TOOTH. 


617 


It  sometimes  becomes  necessary  to  remove  the  artificial  crown, 
and  in  doing  this,  the  pivot  often  remains  in  the  root.  For  the 
extraction  of  this,  the  forceps  represented  in  Fig.  174,  invented 
by  Dr.  W.  H.  Elliott,  will  be  found  very  useful.     With  this  in- 


FiG.  174. 


strument  the  pivot  may  be  removed  from  the  root  without  jarring 
it  in  the  least,  or  exerting  any  extractive  force  upon  it.  The 
manner  of  applying  and  using  the  instrument  will  be  readily  un- 
derstood by  examining  the  drawing. 

When  a  metallic  pivot  is  used,  the  end  going  into  the  artificial 
crown  may  be  fastened  in  either  of  the  following  ways.  First, 
by  cutting  a  screw  on  it,  either  with  a  file,  or  passing  it  through 
a  screw  plate  ;  the  cavity  in  the  crown  should  next  be  filled  with 
a  wooden  tube,  and  the  pivot  then  screwed  into  it :  or  the  pivot 
may  be  first  screwed  into  a  small  block  of  pivot  wood  and  the 
wood  then  trimmed  to  fit  the  crown.  Second,  by  filling  the  pivot 
hole  with  pulverized  borax,  moistened  with  water,  inserting  the 
end  of  the  pivot  into  it,  which  should  be  large  enough  to  fill  the 
cavity,  placing  several  small  pieces  of  solder  around  it,  and  fus- 
ing them  with  the  blow-pipe.  The  solder,  adapting  itself,  when 
in  a  state  of  fusion,  to  the  rough  walls  of  the  cavity  in  the  crown 
of  the  tooth,  will  prevent  the  pivot  from  loosening  or  coming  out. 
The  projecting  part  of  the  pivot  should  be  about  half  an  inch  in 
40 


618  MANNER    OF    SECURING   A    PIVOT    TOOTH. 

length,  square  and  pointed.  The  cavity  in  the  root,  which  re- 
quires to  be  deeper  for  a  metallic  than  for  a  wood  pivot,  should 
be  filled  with  wood,  having  a  small  hole  through  the  centre. 
Fig.  175.  Ii^to  '^li'S)  tl^®  ^^^  ^^  t^^  pivot  is  introduced  and  forced 
up,  until  the  tooth  and  root  come  firmly  together. 
The  appearance  of  a  porcelain  tooth,  prepared  with  a 
metallic  pivot,  for  insertion  in  this  manner  is  shown 
in  Fig.  175.  Another  method  is  to  have  the  part  of 
the  pivot  that  enters  the  root  perfectly  smooth  and  cylindrical ; 
fit  it  into  a  block  of  pivot  wood,  and  then  trim  the  wood  so  as  to 
fit  the  canal  in  the  root. 

But  when  a  metallic  pivot  is  used,  a  plate-tooth  is  preferable 
to  one  made  expressly  for  pivoting.  The  manner  of  attaching  a 
pivot  to  the  former,  is  as  follows  :  the  root  is  first  prepared,  after 
which,  an  impression  is  taken ;  from  this,  a  plaster  model  is 
made,  and  from  the  latter,  metallic  dies.  This  done,  a  piece  of 
gold  plate,  large  enough  to  cover  the  root,  should  be  swaged  up 
between  the  dies,  a  plate  tooth  of  the  proper  size,  shape  and 
color,  is  then  fitted  to  the  root,  backed  with  gold,  and  soldered 
to  the  plate.  To  the  upper  or  convex  surface  of  this  last,  and 
immediately  beneath  the  canal  in  the  root,  a  gold 
.  ^'^'  pivot  is  attached.  The  position  and  direction  of 
f'\  fHiji  this  pivot  is  thus  secured.  Press  the  plate 
|||i  covered  with  a  very  thin  film  of  wax,  against 
iSJ^       wpr     ^j^^  ^^^^^^  _  ^^  ^j^^  point  opposite  the  canal,  thus 

■  '        marked  on  the  plate,  drill  a  hole  ;  through  this 

pass  the  gold  pivot  into  the  canal ;  press  softened 
sealing-wax  around  the  part  of  the  pivot  (made  purposely  too 
long)  below  the  plate,  and  remove  the  fixture  from  the  mouth. 
Invest  the  upper  part  of  the  pin  and  plate  in  plaster,  (keeping 
it  by  means  of  a  minute  collar  of  wax,  out  of  the  hole  through 
which  the  pin  passes,)  remove  the  sealing-wax,  cut  ofl'  the  pin 
even  with  the  plate  and  solder.  A  front  and  side  view  of  a  tooth 
thus  prepared  is  shown  in  Fig.  176. 

A  pivot,  consisting  of  gold  encased  in  a  thin  layer  of  wood, 
constitutes  about  as  secure  a  means  of  attachment  as  can  be  em- 
ployed. It  is  prepared  in  the  following  manner.  The  gold  is 
first  made  into  wire  of  the  proper  size,  and  passed  through  a 
screw-plate :  a  hole  is  then  drilled  lengthwise  into  a  piece  of  well 


I 


MANNER    OF    SECURING    A    PIVOT    TOOTH.  610 

■reasoned  hickory,  as  far  as  required  for  the  length  of  the  pivot, 
and  a  thread  cut  with  the  corresponding  screw-tap  :  into  this  the 
wire  is  screwed,  and  then  cut  oiF  close  to  the  wood,  which  is  re- 
duced with  a  file  or  knife,  to  near  tlie  size  of  the  orifice  in  the 
artificial  crown,  and  then  condensed  by  passing  through  a  pivot 
draw-plate.  Subsequent  manipulations  are  the  same  as  given  for 
the  simple  wooden  pivot ;  from  which  it  differs  in  being  stronger, 
also  in  permitting  a  slight  bend  in  the  pivot,  in  case  the  canals 
in  root  and  crown  are  not  in  precisely  the  same  direction.  The 
wood  prevents  the  gold  from  enlarging  the  cavity  of  the  root,  or 
from  being  worn  by  friction  in  the  pivot  hole  of  the  artificial 
tooth ;  and  at  the  same  time,  by  the  SAvelling  of  this  encasement, 
the  pivot  is  firmly  retained  in  both. 

There  is  some  diversity  of  opinion  with  regard  to  the  best 
kind  of  pivot.  Some  prefer  wood,  others  metal.  Dr.  Fitch,  on 
this  subject,  observes  :  "  The  metallic  pivots  are  far  better  than 
any  other  ;  and  their  only  objection  is,  that  they  are  apt  to  wear 
the  tooth  that  is  placed  upon  them,  and  the  stump  in  which  they 
are  inserted ;  and  so  much  so  do  they  have  this  effect,  that  we 
are  induced  to  use  pivots  of  wood.  This  last  has  the  advantage, 
if  perfectly  seasoned,  of  swelling  in  the  stump,  by  the  moisture 
which  they  absorb  ;  and,  in  this  way,  becoming  very  firm.  The 
advantages  and  disadvantages  of  the  two  kinds,  are,  perhaps, 
nearly  balanced." 

To  the  use  of  wood.  Dr.  Koecker  is  decidedly  opposed.  "  The 
pivots  should  be  made  only  of  fine  gold  or  platina  ;  every  other 
metal,  such  as  brass,  copper,  silver,  and  even  inferior  gold,  are 
highly  objectionable,  being  more  or  less  liable  to  corrode,  and 
thus  become  injurious  to  the  other  teeth  and  the  general  health. 
There  is,  however,  a  practice  which  is  still  more  improper,  name- 
ly, the  use  of  pivots  made  of  wood  ;  these  pivots  expand  con- 
siderably after  insertion,  from  the  moisture  of  the  mouth,  and 
consequently  remain  perfectly  firm  in  the  roots  for  several  years, 
which  deceives  not  only  the  patient,  but  the  dentist  also,  and  in- 
duces them  to  consider  the  case  very  successful  ;  until  they  at 
last  find  that  the  root  is  either  split  by  the  swelling  of  the  pivot, 
or  nearly  destroyed  by  the  rapid  decay  of  the  wood  in  the  cavity  ; 
which,  by  its  chemical  and  mechanical  irritation,  is  very  apt  to 
produce  very  serious  inflammation,  and  other  affections  of  the 


1 


620  MANNER    OF    SECURING    A    PIVOT    TOOTH. 

gums  and  sockets  ;  by  no  means  the  least  objection,  is  the  disa- 
greeable breath,  ■which  must  be  an  unavoidable  concomitant  of 
this  practice.  I  have  made  it  an  universal  rule  to  insert  the 
tooth  in  such  a  manner,  that  the  patient  shall  be  able  after  re- 
ceiving the  necessary  instructions,  to  remove  it,  and  replace  it, 
at  pleasure ;  for  this  purpose,  I  have  found  it  best,  and  most 
effectual,  to  wind  a  little  cotton  round  the  pivot,  which  should 
be  filed  somewhat  rough,  previous  to  its  insertion  into  the  fang." 

The  description  here  given  of  the  effects  supposed  to  be  pro- 
duced by  a  wood  pivot,  is  exaggerated.  If  properly  made  of 
good  Avood,  it  is  no  more  liable  to  produce  irritation,  and  to  affect 
the  breath,  than  one  made  of  gold  or  any  other  metal,  and  wrap- 
ped in  cotton.  The  fact  that  wooden  pivots  remain  firmly  in  the 
roots  for  several  years,  ought  rather  to  be  considered  as  a  recom- 
mendation, than  an  objection,  and  would  go  far  towards  deter- 
mining our  preference  in  their  favor.  The  frequent  removal  and 
replacement  of  a  pivoted  tooth,  greatly  tends  to  hasten  the  de- 
struction of  the  root,  and  to  irritate  surrounding  parts,  and  pre- 
vents the  possibility  of  having  a  firmly  fitting  crown.  In  fact, 
we  are  disposed  to  regard  the  wooden  pivot,  either  simple,  or 
stiffened  by  a  gold  wire,  as  much  the  best  for  a  sound  fang  nor- 
mally placed  in  the  alveolus. 

As  a  general  rule,  not  more  than  two  roots  should  be  prepared 

at    one    sitting,    thoufjh    sometimes 
Fig.  177.  .  ^  , 

four,  or  even  six,  may  be  prepared 

.     __       _  .     ,       without    incurrinfj;    anv  risk.     Fig. 

'  Jk  JL    >A|.  (jflra.'C/        177  represents  the  roots  of  the  four 
W^PWipfflPi  upper  incisors,  prepared  for  the  re- 

ception of  artificial  teeth,  and  the 
teeth  armed  with  wood  pivots,  ready  to  be  inserted.  The  artist 
has  not,  however,  given  a  sufficient  convexity  to  the  ends  of  the 
roots,  nor  carried  down  the  points  of  the  gum  far  enough  between 
the  teeth. 

When  a  tooth  is  attached  by  any  of  the  ordinary  modes  of 
pivoting,  the  walls  of  the  canal  in  the  root  are,  of  necessity, 
exposed  to  the  action  of  the  fluids  of  the  mouth,  and,  conse- 
quently, are  gradually  softened  and  broken  down ;  so  that,  in 
the  course  of  a  few  years,  a  larger  pivot  will  be  required,  and 
this,  too,  will  have  to  be  again  replaced  with  one  still  larger, 


MANNER    OF    SECURING    A    PIVOT    TOOTH.  621 

until,  finally,  the  root  is  destroyed.  This  destructive  process 
proceeds  more  rapidly  in  some  cases  than  in  others,  accordingly 
as  the  root  is  hard  or  soft,  and  as  the  secretions  of  the  mouth 
are  in  a  healthy  or  vitiated  condition.  This  may  be  prevented 
by  introducing  a  gold  cylinder  for  the  reception  of  the  pivot. 
This  protects  the  walls  of  the  canal  against  the  action  of  corro- 
sive agents,  and  a  root  thus  prepared,  will  support  an  artificial 
crown  more  than  twice  as  long  as  when  prepared  in  the  ordinary 
way.  The  operation,  however,  is  more  tedious  and  expensive, 
and  only  the  larger  roots  will  permit  the  enlarged  size  of  canal 
required. 

For  the  preparation  of  a  tooth  in  this  manner,  the  following 
is  the  method  of  procedure:  First,  the  crown  of  the  natural 
tooth  is  removed,  the  nerve,  if  alive,  destroyed,  and  the  canal  in 
the  root  enlarged  as  before  directed.  Secondly,  a  screw-tap  is 
then  introduced  for  the  purpose  of  cutting  a  screw  on  its  inner 
walls.  Thirdly,  a  corresponding  screw-thread  is  then  cut  on  a 
piece  of  hollow  gold  wire,  during  which  process  the  gold  tube  is 
filled  with  steel  wire  to  prevent  compression.  This  done,  it  may 
be  screwed  into  the  root  about  a  quarter  of  an  inch ;  the  wire 
on  the  inside  of  it  is  then  withdrawn,  and  the  lower  or  protrud- 
ing extremity  dressed  ojQT  even  with  the  root  with  a  very  fine 
file.  Fourthly,  an  artificial  tooth  is  selected,  of  the  right  size, 
shape  and  color,  and  fitted  to  the  root;  after  which  a  gold  pivot 
is  fixed  in  it  in  the  manner  before  described,  corresponding  in 
size  and  length  to  the  gold  tube  in  the  root.  Having  proceeded 
thus  far,  the  operation  is  completed  by  applying  the  tooth  to  the 
root,  but  little  pressure  being  required  to  force  up  the  pivot. 

The  stability  of  a  tooth  secured  in  this  manner,  if  the  pivot  be 
of  the  proper  size,  is  as  great  when  first  inserted,  as  one  pre- 
pared by  any  of  the  other  methods,  and  it  may  be  removed, 
cleansed  and  replaced  at  the  pleasure  of  the  patient.  But  metal 
against  metal  inevitably  wears  loose,  and  rapidly  so  if  removed 
from  time  to  time.  Hence  many  prefer  the  wooden  pivot,  with 
a  wire  run  through  its  centre.  When  the  walls  of  the  canal  are 
so  much  enlarged  by  decay  as  to  have  formed  a  conical-shaped 
cavity  in  the  lower  extremity  of  the  root,  the  upper  end  only  of 
the  cylindrical  screw  will  take  cfl'ect.  In  this  case,  the  space 
between  the  lower  extremity  and  the  walls  of  the  root  must  be 


622  MANNER    OF    SECURING    A    PIVOT   TOOTH. 

thoroughly  filled  with  ffold  before  the  wire  on  the  inside  is  Avith- 
drawn ;  after  which  the  tube  and  extruding  portions  of  the  gold 
are  filed  off  even  with  the  root,  and  polished  before  the  artificial 
tooth  is  applied. 

The  hollow  wire  is  made  by  partially  folding  a  narrow,  evenly- 
cut  strip  of  gold  around  a  steel  mandril  (a  knitting-needle  makes 
an  excellent  one),  and  passing  through  a  draw-plate;  withdraw 
the  mandril  and  solder  the  seam ;  then  replace  the  mandril,  and 
complete  the  drawing  until  the  proper  thickness  is  given.  If  too 
thin,  it  will  not  hold  the  screw-thread;  if  too  thick,  it  will  either 
make  the  canal  too  small,  or  require  too  large  an  opening  in  the 
root.  Hollow  wire  may  be  procured  of  the  proper  size  at  less 
expense  of  time  and  money  than  it  can  be  made  by  a  dentist. 
It  is  known  by  jewelers  as  joint-ivire,  because  used  for  the 
hinges  of  breast-pins,  &c. 

It  sometimes  happens  that  the  natural  root,  instead  of  occu- 
pying its  proper  position  in  the  jaw,  runs  very  obliquely,  so  that 
if  the  pivot  connecting  the  artificial  tooth  to  it  be  straight,  the 
latter  will  either  overlap  the  adjoining  teeth,  or  else  project 
outward  or  inward.  To  obviate  this,  an  angle  should  be  given 
to  the  pivot,  immediately  at  the  point  of  junction  between  the 
tooth  and  root.  If  this  obliquity  be  slight,  the  wooden  pivot, 
stiffened  with  wire,  can  easily  be  bent  to  suit;  but  in  cases  of 
greater  obliquity,  a  solid  gold  pin  will  be  required. 

It  sometimes  happens  that  cases  are  met  with  presenting  a 
still  more  formidable  difficulty .  as,  for  example,  when  the  root 
is  situated  behind  the  circle  of  the  other  teeth.  In  a  case  of 
this  sort,  a  different  kind  of  tooth  and  an  entirely  different 
course  of  procedure  is  necessary.  After  having  prepared  the 
root,  an  impression  of  the  parts  are  taken  in  wax,  from  which  a 
plaster  model  is  obtained,  and  from  this  two  metallic  dies.  With 
these  a  gold  plate  is  to  be  swaged,  extending  just  far  enough 
back  to  cover  the  root,  and  forward  to  form  a  line  with  the  outer 
circle  of  the  teeth.  To  the  posterior  part  of  the  plate  covering 
the  root,  and  directly  beneath  the  cavity  in  it,  a  gold  pivot, 
about  three-eighths  of  an  inch  long,  is  soldered  (its  length  and 
direction  is  found  as  directed  on  page  618),  and  to  the  anterior 
part  of  it  a  plate-tooth  of  the  right  size,  shape  and  shade  is  at- 
tached.    A  piece  of  hollow  wood,  or  a  hollow  gold  screw  as 


I 


MANNER   OF   SECURING    A    PIVOT   TOOTH.  623 

before  described,  is  now  introduced  into  the  root,  and  into  this 
the  gokl  pivot  is  inserted.  A  side  view  of  a  right  superior  cen- 
tral incisor,  mounted  on   a  plate  with   a 

.,».,..,,  I,  1  Fig.  178.  Fio.  179. 

pivot,  tor  insertion  m  the  manner  here  de- 
scribed, is  represented  in  Fig.  178.  In 
Fig.  179  a  back  view  is  shown. 

A  description  of   the  manner — of  ob- 
taining impressions  with  wax,  plaster,  &c. ; 

of  making  plaster  models  and  metallic  dies;  of  fitting  a  plate, 
attaching  teeth  to  it,  and  finishing  it  up,  will  be  hereafter  de- 
scribed. But  before  we  proceed  to  do  this,  it  will  be  proper  to 
offer  a  few  remarks  on  the  manner  of  refining  and  alloying  gold, 
and  of  making  it  into  plate,  springs  and  solder. 


CHAPTER    SIXTH. 

MANNER  OF  REFINING  AND  ALLOYING  GOLD,  AND 
CALCULATING  ITS  FINENESS. 

Gold,  as  has  already  been  stated,  is  the  best  metal  which  can 
be  employed  in  connection  with  artificial  teeth,  mounted  in  the 
ordinary  way.  It  is  the  only  one  capable  of  resisting  the  ac- 
tions of  the  secretions  of  the  mouth,  except  platina,  which,  in 
this  respect,  answers  equally  well.  The  latter,  however,  is  better 
suited  for  a  peculiar  style  of  work,  hereafter  to  be  described, 
than  for  the  ordinary  swaged  plate.  Although  for  this  purpose 
it  is  used  to  some  extent,  it  has  no  advantage  in  respect  of  purity 
over  twenty-carat  gold,  and  has  the  decided  disadvantage  of 
being  heavier,  softer,  and  more  easily  bent  out  of  shape.  Gold, 
therefore,  standing  first  in  value  and  importance  of  all  the  mate- 
rials upon  which  artificial  teeth  can  be  mounted,  demands  our 
first  consideration. 

Although  the  manner  of  refining,  alloying  and  manufacturing 
gold  into  plate,  solder,  &c.,  may  not,  perhaps,  be  regarded  as 
coming  properly  within  the  province  of  the  dentist,  yet,  as  he 
often  experiences  great  difficulty  in  procuring  them  of  the  right 
quality,  a  brief  description  of  these  several  processes  is  neces- 
sary. Especially  is  this  necessary  since  the  dental  depots  sel- 
dom keep  on  hand  any  gold  plate  finer  than  eighteen  carats,  the 
use  of  which  we  consider  discreditable  to  the  profession  which 
calls  for  so  inferior  a  quality  of  metal,  rather  than  to  those  whose 
business  it  is  to  supply  their  demands.  IMoreover,  many  practi- 
tioners are  so  situated  that  they  cannot  use  gold  plate,  unless 
they  know  how  to  prepare  it  from  coin. 

Gold  in  its  pure  state,  free  from  alloy,  is  too  soft  and  yielding 
to  serve  as  a  suitable  support  for  artificial  teeth ;  but  if  it  con- 
tains too  much  or  an  improper  alloy,  it  will  either  be  tarnished 
or  blackened  by  the  secretions  of  the  mouth,  or  rendered  too 
brittle  for  dental  purposes.     It  is  of  the  utmost  importance  that 


HEFINING  AND  ALLOYING  GOLD.  625 

the  gold  used  in  connection  with  artificial  teeth  should  be  of  the 
proper  fineness,  and  possessed  of  the  requisite  malleability.  To 
.secure  these  qualities,  it  is  necessary  to  know  the  kind  and 
quantity  of  metal  with  which  it  should  be  alloyed  before  it  is 
made  into  plate  or  other  forms  necessary  for  the  purposes  for 
which  it  is  to  be  employed. 

The  scraps  and  filings  removed  in  shaping  and  reducing  to 
their  proper  size  and  form  the  various  pieces  of  gold  used  in  the 
construction  of  a  piece  of  dental  mechanism,  are  apt  to  become 
mixed  with  base  metals,  such  as  iron  from  the  wearing  of  files, 
and,  occasionally  small  particles  of  lead,  or  tin.  If  these  are 
melted  with  and  permitted  to  remain  in  the  gold,  they  will  de- 
stroy its  ductility,  and  render  it  unfit  for  a  base  or  support  to 
artificial  teeth.  Iron  is  less  objectionable  than  the  lead  or  tin, 
and  may  always  be  removed,  before  the  gold  is  melted,  with  a 
magnet ;  but  to  free  it  perfectly  from  the  others,  it  will  some- 
times be  necessary  to  refine  it  in  the  manner  presently  to  be  de- 
scribed. A  two-thousandth  part  of  tin  or  lead  destroys  the  duc- 
tility of  gold,  and  even  exposure  to  the  fumes  of  red  hot  tin  or 
lead,  renders  it  exceedingly  hard  and  brittle.  Antimony,  or  bis- 
muth, when  mixed  with  gold,  exerts  upon  it  a  very  similar  effect. 
So  marked  is  the  influence  of  antimony,  in  injuring  one  of  the 
most  valuable  properties  of  gold,  that  its  original  name  regulus, 
(little  king,)  by  which  it  is  best  known  in  commerce,  was  given 
in  view  of  this  controlling  effect  upon  the  king  of  metals.  It  is 
of  the  utmost  importance  to  bear  in  mind  the  action  of  minute 
quantities  of  these  four  metals,  so  much  used  in  the  laboratory, 
upon  gold,  platina  and  silver. 

Platina,  united  with  gold  in  certain  proportions,  has  the  effect 
of  hardening  the  latter  metal  and  making  it  very  elastic,  but 
does  not  materially  affect  its  ductility.  The  affinity  of  the  alloy 
for  oxygen  however'is  so  great,  that  it  is  readily  acted  Upon  by 
nitric  acid.  The  septic  (nitrous)  acid  of  the  mouth,  would,  in 
most  cases,  be  apt,  in  a  short  time,  to  corrode  the  metal  or  else 
m^ke  it  very  brittle.  But  for  this,  the  two  metals  combined  in  the 
proportion  of  fifteen  parts  of  gold  to  one  of  platina,  would  form  an 
exceedingly  useful  alloy  for  the  construction  of  spiral  springs. 
That  a  combination  of  two  metals  should  be  thus  easily  acted  on 
by  an  agent  incapable  of  acting  on  either,  when  in  a  separate 


626  MANNER    OF    REFINING   GOLD. 

State,  may  appear  somewhat  remarkable,  hut  it  is,  nevertheless, 
true.  We  have  in  the  effect  of  platina  upon  steel  an  analogous 
case.  It  makes  tlie  steel  exceedingly  hard  and  fine  grained  ; 
but  although  itself  totally  insensible  to  the  action  of  oxygen, 
when  alloyed  in  minute  quantity  with  steel,  it  causes  this  latter 
metal  to  oxidize  with  such  readiness  as  to  make  it  unfit  for  use. 

Hence  may  be  seen  the  fallacy  of  the  idea  entertained  by 
many,  that  because  platina  is  a  more  indestructible  metal  than 
silver  or  copper,  it  must  necessarily  make  a  purer  plate.  The 
properties  of  alloys  are,  in  fact,  so  often  and  so  widely  different 
from  those  of  their  component  metals,  that  they  can  be  ascer- 
tained only  by  experiment.  Of  the  three  metals,  platina,  silver, 
and  copper,  speculative  theory  might  select  the  first  and  purest 
as  the  best  alloy  for  gold ;  whereas  actual  experience  demon- 
strates that  copper,  itself  the  most  injurious  to  the  mouth,  im- 
parts most  perfectly  to  gold,  those  qualities  which  are  required 
in  a  dental  plate. 

In  view,  then,  of  the  importance  of  having  gold,  which  is  to 
be  placed  in  the  mouth,  of  the  right  quality,  every  dentist,  who 
has  connected  with  his  practice  a  mechanical  laboratory,  should 
have  the  necessary  fixtures  for  melting  and  working  this  metal 
into  the  various  forms  required  for  dental  purposes.  The  prin- 
cipal of  these  are,  a  small  furnace,  with  crucibles  and  tongs, 
ingot  moulds,  an  anvil  and  hammers,  and  a  rolling  mill ;  a  plate- 
gauge,  draw-plate,  and  bench-vice ;  fluxing  and  refining  chemi- 
cals, &c.     These  ^^l\\  hereafter  be  described. 

MANNER  OF  REFINING  GOLD. 

It  is  not  our  intention,  in  describing  the  manner  of  refining 
gold,  to  enter  into  a  minute  detail  of  the  various  methods  em- 
ployed for  assaying  or  refining  this  metal ;  *l3ut  to  point  out,  as 
briefly  as  possible,  the  manner  of  separating  it  from  the  several 
metals  with  which  it  is  most  frequently  combined  in  the  dentist's 
laboratory. 

The  method  usually  employed  by  assayers  for  separating  gold 
from  silver,  is,  to  roll  the  alloy  out  into  very  thin  plates,  and 
put  it  in  nitric  acid  ;  this  will  dissolve  most  of  the  silver,  and 
leave  the  gold  behind  in  the  form  of  brown  plates,  scales  or  pow- 


MANNER    OF    REFINING    GOLD.  627 

der,  -whicli  after  being  thoroughly  washed  is  put  into  a  crucible 
with  borax  and  melted  down  into  an  ingot  of  pure  gold.  But 
this  method  will  not  succeed,  unless  the  quantity  of  silver  be 
equal  to  two  or  three  times  that  of  the  gold :  for  the  nitric  acid 
which  acts  only  upon  the  silver  (and  copper)  cannot  eat  out  all 
the  alloy  if  its  particles  are  too  much  surrounded  with  the  parti- 
cles of  gold.  From  the  old  rule — one-fourth  gold,  three-fourths 
alloy — came  the  name  given  to  this  process,  quartration :  it  is 
also  known  as  the  nitric  acid  process.  It  is  well  adapted  to  the 
purification  of  gold  upon  a  large  scale,  and  is  the  process  used 
in  the  U.  S.  Mint.  But  it  does  not  remove  the  platina  so  gene- 
rally found  in  dentist's  scrap ;  and  is  not  so  well  adapted  for 
gold  of  eighteen  carats  fineness  and  upward  as  the  next  process. 

The  Nitro-Muriatic  or  Aqua-Regia  process  dissolves  all  the 
metals  of  the  alloy,  but  immediately  precipitates  the  silver.  The 
gold  is  subsequently  precipitated  in  a  state  of  purity,  thoroughly 
washed,  dried  and  melted  down  with  borax.  The  process  is 
briefly  as  follows.  Melt  the  scrap  to  be  refined ;  roll  into  a  thin 
strip  and  curl  it  up  into  what  is  technically  termed  a  cornet ; 
place  in  a  porcelain  vessel  and  pour  on  the  aqua-regia,  three  or 
four  ounces  to  the  ounce  of  alloy,  which  must  be  mixed  at  the 
moment  of  using,  in  the  proportion  of  one  part  of  pure  nitric 
acid  to  two,  two  and  a  half,  or  three  parts  of  hydrochloric  acid: 
quicken  the  solution  by  heat  from  a  spirit  lamp,  setting  the 
vessel  where  the  nitrous  fumes  can  escape  from  the  room  :  decant 
or  filter  the  solution  so  as  to  separate  the  precipitated  silver  : 
evaporate  the  clear  solution  over  a  spirit-lamp  nearly  to  dryness, 
add  hydrochloric  acid  and  evaporate  a  second  time,  so  as  to  get 
rid  of  all  nitric  acid. 

This  concentrated  orange  colored  solution  is  the  chloride  of 
gold  together  with  the  chloride  of  platina  and  other  metals  from 
which  it  must  be  separated  by  precipitation.  Dilute  largely 
with  water,  and  add  little  by  little,  a  solution  of  the  proto-sul- 
phate  of  iron,  (green  vitriol,)  until  the  dark  olive-brown  precipi- 
tate, which  instantly  appears,  ceases  to  form.  Pour  on  this  pre- 
cipitate some  sulphuric  acid  to  remove  all  trace  of  iron,  and  then 
wash  several  times  with  hot  water,  dry  it  and  melt  with  borax 
in  a  crucible. 

If  the  presence  of  much  platina  is  suspected,  the  solution 


628  MANNER    OF    REFINING    GOLD. 

should  be  treated  with  muriate  of  ammonia  (sal-ammoniac)  after 
the  gold  has  been  removed.  This  will  precipitate  the  platina 
which  should  be  washed,  dried,  and  sold,  inasmuch  as  the  den- 
tist has  no  heat  sufficiently  intense  to  melt  it.  If  the  alloy  to 
be  refined  consists  simply  of  gold  and  platina,  the  aqua-regia 
solution,  after  being  made  neutral  by  twice  evaporating  nearly 
to  dryness,  should  be  diluted  with  water  and  the  platina  precipi- 
tated by  muriate  of  ammonia  ;  then  decant  the  gold  solution  from 
the  platina  and  precipitate  the  gold  by  the  proto-sulphate  of 
iron. 

A  third  method  of  refining  is  the  sulphuric  acid  process,  which 
it  is  unnecessary  to  describe  further  than  to  say  that  it  resem- 
bles the  quartation  process.  Gold  is  melted  with  five  to  seven 
times  as  much  silver,  granulated  and  then  boiled  three  or  four 
hours  in  a  platina  or  iron  retort  with  sulphuric  acid. 

By  any  of  these  three  processes,  but  most  conveniently  by  the 
second,  dental  scrap  may  be  refined  to  a  purity  sufficient  for 
every  practical  purpose.  The  assayer  resorts  to  other  methods 
to  obtain  the  absolute  purity  required  in  analyses. 

Gold  still  containing  traces  of  silver  may  be  treated  with  sul- 
phuret  of  antimony.  This  may  be  done  with  a  strong  heat  in  a 
covered  crucible,  and  after  the  gold  has  been  kept  in  a  state  of 
fusion  for  some  thirty  or  forty  minutes  it  should  be  poured  out 
into  an  ingot  mould,  and  separated  from  the  antimony  which 
will  lie  at  the  top.  It  may  be  necessary  to  melt  it  in  this  way 
two  or  three  times,  adding,  each  time,  a  less  quantity  of  anti- 
mony ;  at  the  last  melting,  a  current  of  air,  from  a  pair  of  bel- 
lows, should  be  thrown  upon  the  surface  of  the  fused  metal  to 
evaporate  the  antimony,  and  after  the  vapor  ceases  to  escape,  a 
little  refined  nitre  and  borax  should  be  thrown  into  the  crucible. 
It  should  then,  in  a  few  minutes,  be  poured  into  the  ingot  mould 
and  rolled ;  should  it  crack  in  hammering  or  rolling,  it  must  be 
again  melted,  and  a  little  more  nitre  and  borax  thrown  on  it. 

Still  another  process  for  refining  gold,  is  occasionally  used, 
called  cementation.  It  consists  in  first  rolling  the  gold  out 
into  exceedingly  thin  plates,  then  placing  it  in  a  crucible  with  a 
mixture  of  four  parts  of  brick-dust,  one  of  calcined  sulphate  of 
iron,  and  one  of  chloride  of  soda.  A  bed  of  this  mixture  or 
cementing  powder,  is  first  placed  in  the  bottom  of  the  crucible ; 


MANNER    OF    REFINING    GOLD.  629 

the  gold  is  then  put  in  and  covered  with  it.  The  crucible  is 
covered  with  another  crucible,  the  joints  well  luted  with  clay, 
and  gradually  raised  to  a  red  heat,  at  which  temperature,  it 
should  be  kept  from  twenty  to  twenty-four  hours.  The  crucible 
is  then  removed  from  the  fire,  the  top  broken  off,  and  after  it  has 
cooled  the  gold  may  be  separated  from  the  cement  and  washed, 
or  what  is  still  better,  boiled  in  hot  water.* 

The  form  of  furnace  for  melting  gold  depends  much  upon  the 
kind  of  fuel.  Charcoal,  coke  and  anthracite  are  the  three  kinds 
used  ;  bituminous  coal  is  inadmissible  until  converted  into  coke. 
The  stove  factories  now  furnish  so  many  convenient  forms  for 
the  use  of  any  of  these  fuels,  that,  we  shall  not  occupy  time  or 
space  in  their  detailed  description.  A  pipe  six  feet  high  will 
give  to  the  ordinary  "preserving  furnace"  a  draft  sufficient  to 
melt  gold  with  charcoal :  coke  gives  a  very  intense  heat,  but 
needs  a  stronger  draft ;  anthracite  requires  a  powerful  draft,  but 
gives  a  more  steady  heat,  need  less  frequent  renewal,  and  hence 
is  better  for  long  continued  heats. 

As  regards  the  shape  and  size  of  the  stove,  the  following  points 
should  be  attended  to.  Convenience  of  access  to  the  crucible  ; 
sufficient  depth  and  width  to  surround  the  crucible  with  a  good 
body  of  fuel,  without  unnecessary  waste  of  material.  Furnaces 
acting  by  simple  draft,  will  be  found  to  answer  better  than  blast 
furnaces. 

The  Ceylonese  goldsmiths  use  a  blast  furnace  of  very  rude 
and  simple  construction.  It  consists  of  a  small  low  earthen  pot, 
filled  with  chaff,  or  saw-dust,  on  which  a  little  charcoal  fire  is 
made,  which  is  excited  with  a  small  bamboo  blow-pipe,  about  six 
inches  long,  the  blast  being  directed  through  a  short  earthen  pipe 
or  nozzle,  the  end  of  which  is  placed  at  the  bottom  of  the  fire.  By 
this  simple  contrivance,  a  most  intense  heat  may  be  obtained, 
greater,  it  is  said,  than  is  required  for  melting  gold  or  silver. 

For  separating  copper,  tin,  lead  or  zinc,  from  gold,  the  follow- 
ing simple  method  may  be  adopted  ;  put  the  gold  in  a  clean  cru- 
cible, covered  with  another  crucible,  having  a  small  opening  or 
hole  through  the  top  ;  lute  the  two  together  with  clay,  place  them 
in  a  bed  of  charcoal  in  the  furnace,  ignite  the  coal  gradually, 
afterwards  increase  the  combustion  by  means  of  a  current  of  air 

»  See  Chemistry  of  Arts,  vol.  ii,  pp.  645,  550. 


630  MANNER    OF    REFINING    GOLD. 

from  a  pair  of  bellows  or  by  turning  on  the  draft ;  after  the  gold 
has  melted,  throw  in  at  intervals  of  about  ten  minutes  several 
small  lumps  of  nitrate  of  potash,  (saltpetre,)  and  sub-borate  of 
soda,  (borax,)  and  keep  it  in  a  fused  state  for  thirty  or  forty 
minutes ;  then  remove  the  crucible,  and  plunge  in  water  to  cool 
it ;  break  it  and  separate  the  lump  of  gold  from  the  dross ;  then 
put  into  another  crucible,  melt  with  a  little  borax,  and  pour  into 
an  ingot-mould,  of  the  proper  size,  previously  warmed  and  oiled. 
The  bi-chloride  of  mercury  (corrosive  sublimate)  is  sometimes 
used  instead  of  or  after  the  nitre,  for  the  purpose  of  dissipating  the 
base  metals,  and  often  with  more  certain  and  better  results,  es- 
pecially Avhere  the  presence  of  any  tin  is  suspected.  If  the 
gold  cracks  on  being  hammered  or  rolled,  it  should  be  melted 
again,  and  more  nitre  and  borax  thrown  into  it ;  the  inside  of 
the  crucible  should  also  be  well  rubbed  with  borax,  before  the 
metal  is  put  in.  It  is  sometimes  necessary  to  repeat  this  process 
several  times,  and  if  the  gold  still  continue  brittle,  a  little  muri- 
ate of  ammonia  (sal  ammoniac)  may  be  thrown  into  the  crucible 
when  the  gold  is  in  a  fused  state ;  after  the  vapor  ceases  to  es- 
cape, the  metal  should  be  poured  into  an  ingot  mould,  warmed 
and  oiled  as  before  directed.  This  last  method  of  treatment  will 
make  the  gold  tough,  and  prevent  it  from  cracking  under  the 
hammer,  or  while  being  rolled,  provided  it  is  from  time  to  time, 
properly  annealed  during  the  process. 

By  this  method  of  refining  gold,  known  as  the  dry  process,  or 
"refining  by  fire,"  sufiiciently  accurate  results  will  be  obtained 
for  many  of  the  practical  purposes  of  mechanical  dentistry ; 
since  the  variation  of  an  eighth  or  a  quarter  of  a  carat  in  the 
fineness  of  gold-plate  is  not  often  a  matter  of  much  consequence. 
Comparing  the  two  classes  of  refining  processes — the  humid,  by 
acids;  and  the  dri/,  by  fire — the  first  is  the  more  accurate,  and 
the  only  way  to  remove  platina  or  silver;  but  it  is  the  most 
troublesome,  and  requires  a  familiarity  with  chemical  details, 
which,  unfortunately,  many  dentists  are  totally  ignorant  of. 
The  second  may  remove  the  lead,  tin,  zinc,  antimony  and  bis- 
muth, if  in  small  quantity;  and  if  continued  for  a  suflBcient 
length  of  time,  with  a  free  use  of  nitre,  may  remove  a  large 
proportion  of  copper.  It  can  scarcely  be  depended  upon  if  the  ob- 
ject is  to  make  an  ingot  of  pure  gold,  but  will  answer  admirably 


i 


MANNER    OF    REFINING    GOLD.  631 

if  the  purpose  is  merely  to  lessen  the  alloy  or  remove  certain 
impurities. 

As  the  dry  process  is  one  that  the  dentist  will  often  have  oc- 
casion to  resort  to,  we  shall  give  (from  the  seventh  volume  of  the 
American  Journal  of  Dental  Science)  the  folloAving  description 
of  the  very  excellent  method  pursued  by  Dr.  Elliot,  of  Montreal : 

'"The  following  implements  are  necessary  for  this  purpose:  a 
small  draught  furnace,  a  quantity  of  fine  hard- wood  coal,  a  clean 
crucible  with  a  sheet-iron  cover  (a  lump  of  charcoal  is  better),  a 
light  pair  of  crucible-tongs,  an  ingot-mould  made  of  soapstone, 
a  little  nitrate  of  potash,  carbonate  of  potash,  borax  and  oil. 
The  fire-place  of  the  furnace  should  be  about  ten  inches  in  dia- 
meter, and  eight  or  ten  deep ;  this  should  be  connected  by  means 
of  a  pipe  with  the  chimney,  so  that  a  powerful  draught  may  be 
made  to  pass  through  the  coal.  A  blast-furnace  is  objectionable, 
for  the  reason  that  the  bellows  burns  out  the  coal  immediately 
under  the  crucible,  and  it  is,  therefore,  constantly  dropping 
•I'lwn,  which  is  not  the  case  with  the  draught-furnace;  besides, 
the  draught-furnace  produces  a  more  even  fire,  a  quality  equally 
indispensable. 

"  In  preparing  for  a  heat,  the  furnace  should  be  filled  about 
half  full  of  coal,  and  after  it  is  well  ignited,  it  should  be  con- 
solidated as  much  as  practicable  without  choking  the  draught. 
The  crucible  containing  the  metal  and  a  little  borax  may  then 
be  set  on,  and  more  coal  placed  around  and  over  it,  the  door  of 
the  furnace  closed,  and  the  damper  opened.  It  should  remain 
in  this  way  until  the  gold  is  perfectly  fused.  The  coal  may  then 
be  removed  from  over  the  crucible,  and  a  bit  of  nitrate  of  pot- 
ash dropped  in,  in  quantity  equal  to  the  size  of  a  pea  to  every 
ounce  of  gold,  and  the  crucible  immediately  covered  with  a 
plate  of  iron.  More  coal  may  then  l^e  placed  over  and  around 
the  crucible,  and  the  gold  kept  in  a  fused  state  at  a  high  tem- 
perature, until  the  scoria  ceases  to  pass  off,  which  it  will  do  in 
the  course  of  five  or  six  minutes.  The  ingot-mould  having  been 
previously  warmed,  should  be  placed  in  a  convenient  position 
for  pouring,  and  filled  about  half  full  of  lamp-oil.  The  cover 
should  now  be  thrown  off  quickly,  the  crucible  seized  with  the 
tongs,  and  at  the  same  instant  another  small  bit  of  nitrate  of 
potash  should  be  thrown  into  it,  and  the  gold  rapidly,  but  care- 
fully, poured  into  the  mould. 


632  MANNER    OF    ALLOYING    GOLD. 

"The  ingot  always  cools  first  at  the  edges,  and  shrinks  away 
from  the  middle.  On  that  account,  the  mould  should  be  a  little 
concave  on  the  sides,  so  that  the  shrinking  will  not  reduce  the 
ingot  thinner  in  the  centre  than  at  the  edges. 

"  Moulds  of  the  best  form  will  sometimes  produce  ingots  of 
irregular  thickness.  Such  ingots  should  be  brought  to  a  uniform 
thickness  under  the  hammer,  using  the  common  callipers  as  a 
gauge.  If  this  be  neglected,  the  plate  will  be  found  imperfect 
at  those  points  where  the  ingot  was  thinnest.  The  plate  should 
be  annealed  occasionally  during  the  process  of  hammering  and 
rollinff,  and  should  be  reduced  about  one  number  in  thickness 
each  time  it  passes  between  the  rolls.  If  any  lead,  tin  or  zinc 
be  mixed  with  the  gold,  the  nitrate  of  potash  must  be  used  in 
much  larger  quantities,  and,  in  that  case,  it  is  better  to  let  the 
button  cool  in  the  bottom  of  the  crucible.  Then  break  the  cru- 
cible, and  melt  it  in  a  clean  one  for  pouring,  using  borax  and 
nitrate  of  potash  in  very  small  quantities  for  the  last  melting. 

"In  case  the  subject  of  assay  be  in  the  form  of  filings  or 
dust,  a  magnet  should  be  passed  through  it  so  as  to  remove  every 
particle  of  iron,  and  then,  instead  of  melting  it  with  borax,  it 
should  be  melted  first  with  carbonate  of  potash,  and  afterwards 
Avith  nitrate  of  potash,  in  quantities  proportioned  to  the  necessi- 
ties of  the  case,  as  before  directed.  Carbonate  of  potash  is  the 
only  flux  that  will  bring  all  the  small  particles  of  metal  into  one 
mass.  Without  it,  a  great  portion  of  the  gold  will  be  found 
among  the  scorite,  adhering  to  the  sides  of  the  crucible,  in  the 
form  of  small  globules.  This  process  of  refining  answers  equally 
as  well  for  silver  as  gold." 

ALLOYING  GOLD. 

Gold,  when  in  an  unalloyed  or  pure  state,  as  before  stated,  is 
too  soft  to  be  used  as  a  support  for  artificial  teeth ;  consequently, 
it  has  been  found  necessary  to  combine  with  it  some  other  metal, 
in  order  to  harden  it.  Silver  and  copper  are  the  alloys  most 
frequently  employed.  Many  dentists  prefer  the  former,  errone- 
ously supposing  that  it  does  not  increase  the  liability  of  gold  to 
tarnish  as  much  as  the  latter.  But  this  opinion  is  sustained 
neither  by  facts  nor  experience.     Gold,  when  alloyed  with  cop- 


I 


MANNER    OF    ALLOYING    GOLD.  633 

per,  unless  reduced  altogether  too  much  for  dental  purposes, 
will  resist  the  action  of  acids  as  effectually  as  when  alloyed  with 
.silver,  and  the  former  renders  it  much  harder  than  the  latter. 
Besides,  it  renders  the  gold  susceptible  of  a  higher  and  more 
beautiful  finish.  If,  therefore,  but  one  of  these  metals  is  used, 
copper  may  be  regarded  as  preferable  to  silver;  but  four  or  nine 
parts  of  the  former  with  one  of  the  latter,  constitutes  a  still 
better  alloy  for  gold. 

The  gold  employed  in  mechanical  dentistry  by  most  practi- 
tioners is  altogether  too  impure  for  the  purpose,  it  being  not 
more  than  eighteen  carats  fine,  and  sometimes  it  is  reduced 
even  to  fourteen.  When  not  above  these  standards  of  fineness, 
it  is  discolored  by  the  buccal  secretions,  imparts  a  disagreeable 
taste  to  the  mouth,  and  becomes  brittle  after  it  has  been  worn 
for  a  few  years.  The  plate  which  is  to  serve  as  a  basis  for  arti- 
ficial teeth  should  never  be  reduced  below  twenty  carats,  and  as 
that  for  the  upper  jaw  does  not  require  to  be  more  than  one- 
third  or  one-half  as  thick  as  that  of  the  lower,  the  gold  for  the 
latter  may  be  a  little  finer  than  that  employed  for  the  former, 
as  it  is  necessary  that  it  should  be  more  malleable.  The  follow- 
ing standards  of  fineness  may  be  regarded  as  the  best  that  can 
be  adopted  for  gold  used  in  connection  with  artificial  teeth :  plate 
for  the  upper  jaw,  twenty  carats;  for  the  lower,  twenty-one;  and 
for  clasps  and  wire  for  spiral  springs,  eighteen. 

In  reducing  perfectly  pure,  or  twenty-four  carat,  gold  to  these 
"standards,  first  make  an  alloy  of  copper  and  silver,  which  may  be 
either  in  the  proportion  of  copper  4,  silver  1,  or  copper  9,  silver 
1,  according  to  the  qualities  required  in  the  plate.  The  action 
of  the  two  metals  are  in  strong  contrast — copper  giving  hard- 
ness and  elasticity  and  deepening  the  color  into  a  red ;  silver 
preserving  the  softness,  and  giving  a  greenish-white  shade  to  the 
original  yellow  of  the  pure  gold.  Of  these  alloys  take — to 
twenty-one  grains  of  pure  gold,  three  grains;  to  twenty  grains 
of  pure  gold,  four  grains ;  and  to  eighteen  grains  of  pure  gold, 
six  grains;  to  make,  respectively,  twenty-one,  twenty  and 
eighteen  carat  gold.  In  the  latter  case,  the  alloy  should  be 
used  containing  most  silver,  as  so  large  a  per  centage  of  copper 
makes  the  gold  too  hard  and  elastic,  and  gives  it  rather  too  red 
a  color, 
41 


634  MANNER    OF    ALLOYING    GOLD. 

The  gold  should  be  first  melted  in  a  clean  crucible,  and  as 
soon  as  it  has  become  thoroughly  fused,  the  silver  and  copper 
alloy  may  be  thrown  in,  with  two  or  three  small  lumps  of  borax. 
After  keeping  the  whole  in  a  melted  state  for  some  five  or  ten 
minutes,  it  should  be  quickly  poured  into  an  ingot -mould  of  the 
proper  size,  previously  warmed  and  oiled.  If  the  gold  crack 
during  the  process  of  hammering  or  rolling,  it  must  be  melted 
again,  and  a  few  small  pieces  of  borax,  with  a  little  muriate  of 
ammonia,  thrown  in,  and  in  five  or  ten  minutes  recast  into  an 
ingot. 

When  scraps  and  filings  are  to  be  converted  into  plate,  they 
should  first  be  refined,  afterwards  properly  alloyed.  This  may 
also  be  necessary  with  all  gold  the  quality  or  fineness  of  which 
is  not  known;  but  with  national  coins  having  a  known  fixed 
standard,  this  will  not  be  necessary.  When  they  are  above  these 
standards  of  fineness,  the  amount  of  alloy  necessary  to  reduce 
them  to  the  required  fineness  may  be  readily  found  by  calcu- 
lation. 

In  connection  with  the  alloying  of  gold,  it  is  proper  to  make 
seme  remarks  upon  the  terms  in  which  the  fineness  of  alloys  are 
expressed,  and  the  means  of  ascertaining  it. 

Pure  gold  being  taken  as  the  starting-point,  it  may  be  ex- 
pressed by  unity  (1),  or  by  24,  or  by  1000.  In  the  first  case, 
fineness  is  given  in  fractions.  In  the  second  case,  by  parts, 
called  carats^  which,  for  convenience,  may  be  considered  as 
equivalent  to  a  grain ;  thus  representing  pure  gold  by  24  grains, 
or  1  dwt.  In  the  third  case,  value  is  expressed  in  decimals,  and 
is  the  most  convenient  system,  although  the  second  is  the  most 
customary  with  jewelers  and  dentists. 

The  following  table,  prepared  by  Professor  Austen,  will  show 
the  relative  value  of  these  three  systems  in  a  few  of  the  most 
usual  forms  of  gold  alloy. 


I 


MANNER    OF    ALLOYING    GOLD. 


635 


Fractions. 

Carats. 

Decimals. 

Pure  Gold, 

1. 

24. 

1000. 

English  Coin, 

H 

22. 

916.6 

American  Coin, 

A 

21.G 

900. 

Dentists'  Gold,  best, 

f 

20. 

sn.z 

"             "       good, 

f 

19.2 

800. 

Jewelers'  Gold,  best. 

f 

18. 

750. 

"               "        good, 

i 

15. 

625. 

"               "        common, 

^- 

12. 

500. 

Commonest  Solder, 

i 

8. 

333.3 

The  table  gives  the  amount  of  pure  gold ;  subtracting  which 
from  the  number  at  the  head  of  each  column,  Avill  give  the 
amount  of  alloy.  For  example:  best  jewelers'  gold  contains  18 
larats  of  pure  gold  and  6  carats  of  alloy;  or  three-fourths  pure 
irold  and  one-fourth  alloy ;  or  750  parts  pure  gold  and  250  parts 
alloy. 

To  know  how  much  alloy  is  required  to  reduce  gold  from  one 
ilegree  of  fineness  to  another,  Professor  Austen  gives  the  fol- 
lowing rule  :  Divide  the  loiver  carat  («?)  by  the  difference  between 
the  loiver  carat  (c)  and  the  higher  {0);  divide  the  weight  (W)  of 
the  gold  by  this  quotient  {c-i-{0 — c) ),  and  it  will  give  the  amount 
of  alloy  (A)  to  be  added.  He  also  gives  the  following  table  of 
DIVISORS,  which  will  be  found  convenient,  as  saving  the  necessity 
of  much  calculation : 


Carat. 

22 

21 

20 

19 

18 

16 

14 

12 

24. 

11. 

7. 

5. 

3.8 

3. 

2. 

1.4 

1. 

22. 

21. 

10. 

6.3 

4.5 

2.6 

1.7 

1.2 

21.6 

35. 

12.5 

7.3 

5. 

2.8 

1.8 

1.3 

20. 

19. 

9. 

4. 

2.3 

1.5 

18. 

8. 

3.5 

2. 

The  first  vertical  column  represents  the  fineness  before  alloy- 
ing; the  first  horizontal  column  the  fineness  after  alloying. 
Example:  To  reduce  a  double-eagle  (weighing  516  grains,  and 
21.6  carats  fine)  to  20,  18,  and  12  carat  plate,  divide  the  weight 


636  MANNER    OF    ALLOYING    GOLD. 

by  12|,  5,  and  1^;  this  gives  the  amounts  of  alloy  to  be  added 
— for  the  first,  41.3  grains;  for  the  second,  103.2  grains;  and 
for  the  third,  387  grains. 

When  it  is  required  to  know  the  fineness  of  the  plate  or  solder 
made  from  known  quantities  of  gold  and  alloy,  multiply  the 
weight  (  TF)  of  gold  ^  before  alloying,  by  its  carat  valuation  ( C);  divide 
this  product  {C  W)  by  the  weight  of  the  gold  after  alloying 
(W-\-A);  the  quotient  will  be  the  carat  value  (c)  of  the  alloyed 
gold. 

This  and  the  preceding  rules  may  be  also  expressed  by  alge- 
braic formulae : 

c  C  W 

(1.)        A  =  W^ (2.)         c  = 

C— c  W+A 

The  fineness  of  any  mixture  of  alloys  of  known  value  may  be 
found  by  a  simple  arithmetical  rule.  Multiply  each  weight  by 
its  carat  (pure  gold  being  24),  divide  the  sum  of  the  products  by 
the  sum  of  the  weights,  and  the  quotient  will  be  the  carat-value 
of  the  mass. 


CHAPTER    SEVENTH. 

MANNER  OF  MAKING  GOLD  INTO  PLATE.  SPRINGS  AND 

SOLDER. 


The  gold,  after  being  refined  or  alloyed,  as  the  case  may  be, 

then  remelted  in  a  clean  crucible,  well  rubbed  on  the  inside  with 

borax,  should  be  poured  into  an  ingot-mould  (Figs.  180,  181)  of 

Fig.  180. 


Fig.  181. 


.Iilllil 


the  proper  length,  width  and  thickness;  then,  after  it  has  be- 
come sufficiently  cool,  it  may  be  placed  on  an  anvil,  and  its 
thickness  reduced  to  about  an  eiglith  of  an  incli,  with  a  hammer 
weighing  from  one  to  one  and  a  half  pounds.  It  should  then 
be  well  annealed  by  being  placed  in  the  furnace,  lightly  covered 
with  small  pieces  of  charcoal,  and  heated  until  it  assumes  a  uni- 
form cherry-red  color.  It  may  be  necessary,  during  the  opera- 
tion of  hammering,  to  subject  it  once  or  twice  to  this  process, 
to  prevent  the  gold  from  cracking.  If,  notwithstanding  tliis 
precaution,  it  should  crack,  it  must  be  again  melted,  and  re- 
fined with  muriate  of  ammonia.  Sudflen  cooling  doe.-;  not  make 
it  brittle.  On  the  contrary,  some  jewelers  maintain,  that  if 
plunged  in  alcohol  and  water,  it  is  softer  than  when  slowly 
cooled.  A  little  sulphuric  ncid  in  the  water  will  give  a  bright 
surface  to  the  plate,  by  cleansing  off  the  oxide  of  copper. 


638 


MANNER    OF    MAKING    GOLD    PLATE. 


I 


After  the  f^old  has  been  reduced  to  the  thickness  just  men- 
tioned, and  well  annealed,  it  may  be  placed  between  the  rolls 
of  the  mill,  previously  so  adjusted  as  to  be  the  same  distance 
apart  at  both  ends,  and  not  so  near  to  each  other  as  to  require 
a  great  effort  to  force  it  between  them.  The  rollers,  however, 
should  be  brought  a  little  nearer  to  each  other  every  time  the 
plate  is  passed  between  them,  and  during  this  process  they  should 
be  kept  well  oiled,  so  that  there  may  be  as  little  friction  as  pos- 
ble.  Many  roll  the  ingot  without  any  previous  hammering.  In 
the  process  of  rolling,  care  must  be  had  to  anneal  often  and  to  roll 
in  one  direction  until  sufficient  width  of  plate  is  obtained;  then, 
before  cross-rolling,  be  sure  to  anneal,  else  the  plate  will  be 
very  apt  to  crack. 

Rolling-mills  for  gold  are  variously  constructed.  Some  are 
very  simple,  while  others  are  quite  complex,  having  a  great  deal 
of  machinery  connected  with  them.  The  rollers  also  vary  in 
length,  from  three  to  five  inches.  For  the  gold  plate  used  by 
dentists,  they  need  not  be  more  than  three  or  three  and  a  half 
inches  long.  Fig.  182  represents  a  simple  form  of  rolling-mill, 
without  the  cog-gearing,  as  seen  in  Fig.  183.  The  latter  is  a 
strong  but  simple  mill,  and  is  very  well  suited  to  the  dental  labo- 


FiG.  182. 


Fig.  183. 


ratory.  The  set  screws  at  the  top  are  turned  with  a  rod,  and 
must  be  both  moved  alike,  else  the  plate  will  be  thicker  on  one 
side,  and  will  curve  laterally  in  rolling. 

Fig.  184   represents  a  more   complicated   mill,   designed   for 
those  who  do  much  or  heavy  rolling.     With  such  a  mill,  all  the 


MANNER    OF    MAKING    GOLD    PLATE. 


630 


Fig.  184. 


rolling  of  a   laboratory  could    be   done  without   the   aid  of  an 
assistant. 

The  thickness  of  the  plate  may  be  detennined  by  a  gauge- 
j)late.  That  which  is  to 
serve  as  a  basis  for  artificial 
teeth  for  the  upper  jaw  may 
he  reduced  until  it  fiis  the 
Liauge  at  25,  26  or  27,  ac- 
cording to  the  quality  of 
the  plate  and  the  depth  or 
irregularity  of  the  arch. 
For  the  lower  jaw,  and  for 
Ijackings  and  clasps,  it  may 
range  from  21  to  24.  When 
the  whole  alveolar  border 
and  a  portion  of  the  roof 
of  the  mouth  is  to  be  cov- 
ered, it  may  be  a  little  :^=^mM 
thinner  than  when  applied  C 
only  to  a  small  surface ;  '; 
also  thinner  when  the  arch 
is  deep  or  irregular.  The 
purer  the  gold  is,  the 
thicker  must  be  the  plate. 
When  very  Avide  clasps,  too, 
are  employed,  it  is  not  necessary  that  the  gold  should  be  as 
thick  as  is  required  for  narrow  ones;  and  low  or  wide  backings 
need  not  be  so  tliick  as  long  or  narrow  ones.  Lower  plates, 
if  wired  around  the  edore  or  doubled  over  the  middle  third, 
may  be  made  of  the  same  thickness  as  an  upper  plate.  But 
these  are  matters  which  the  judgment  of  the  dentist  alone  can 
properly  determine,  and,  consequently,  no  rules  can  be  laid 
down  upon  this  subject,  from  wiiich  it  will  nut  sometimes  be  ne- 
cessary to  deviate. 

Gauge  plates  are,  unfortunately,  not  uniform.  For  many 
years  the  most  reliable  were  those  manufactured  by  Stubl)s. 
But  it  is  difficult  to  procure  them.  At  the  same  time,  it  is  very 
important  that  some  standard  should  be  adopted  in  the  profes- 
sion.    Under  these  circumstances,  we  approve  the  suggestion  of 


640 


MANNER    OF    MAKING    GOLD    PLATE. 


Dr.  S.  S.  White,  who  recommends  the  gauge-plate  given  in  Fig. 
185,  which  has  been  adopted  by  the  principal  brass  manufactur- 
ers of  this  country. 


Fig.  185. 


It  may  be  necessary  sometimes  to  make  gold  wire  for  spiral 
springs  or  other  purposes;  also  hollow-tube  wire.     A  draw-plate 


Fig.   186. 


(Fig.  186),  strong  pliers  and  bench-vise  (Fig.  187)  are  all  that 
are  necessary  for  this  purpose.  The  draw-plate  should  be  of  the 
hardest  steel,  and  the  holes  diminishing  very  gradually.  The 
pliers  should  be  rough  at  the  end  for  grasping  the  wire,  which 
must  be  often  annealed  during  the  process. 

The  simplest  metiiod  of  winding  wire  into  a  spiral  spring  is 
to  secure  it  betAveen  two  blocks  of  wood,  held  betAveen  the  jaws 
of  a  small  bench-vise,  as  shown  in  Fig.  187.  The  upper  end 
of  the  wire  is  then  grasped  by  a  hand-vise  or  sliding-tongs,  in 
connection  with  a  spindle  or  steel  wire,  the  size  of  a  small  knit- 


GOLD    SOLDER. 


641 


ting-needle,  six  or  eight  inches   in  length.     The  spindle,  resting 
on  the  blocks  of  wood,  is  made  to  revolve,  and  by  this  move- 


FiG.  187. 


nient  the  gold  wire  is  drawn  through  the  blocks  and  wound  firmly 
and  closely  round  the  steel  rod. 


GOLD  SOLDER. 

In  making  gold  solder,  the  metals  employed  for  the  purpose, 
if  not  pure,  should  be  refined  separately.  Unless  this  is  done, 
it  will  be  difficult,  and  often  impossible,  to  ascertain  their  rela- 
tive purity,  which  should  be  known  to  insure  the  desired  result. 
The  gold  is  placed  in  a  clean  crucible  with  a  little  borax,  and  as 
soon  as  it  has  become  perfectly  melted,  the  silver,  and  after- 
ward the  copper,  are  added.  When  all  are  melted,  the  alloy 
may  be  immediately  poured  into  an  ingot-mould,  previously 
warmed  and  oiled.  The  process  of  hammering  and  rolling  the 
solder  is  the  same  as  that  described  for  gold-plate.  In  conse- 
quence of  the  large  amount  of  alloy  in  solder,  it  is  sometimes  so 
stiff,  and  even  brittle,  as  tb  be  with  great  difificulty  rolled.  This 
difficulty  is  increased  by  the  fact  that  its  low  fusibility  makes  it 
not  very  easy  to  anneal  it  without  melting.  This  is  sehlom  the 
case  with  solders  composed  of  the  three  metals,  gold,  silver  and 
copper,  but  only  when  zinc  or  brass  are  used. 


642  GOLD    SOLDER. 

In  making  solder  into  the  composition  of  which  zinc  enters, 
the  other  ingredients  must  be  thoroughly  melted,  then  the 'zinc 
(or  brass)  introduced  at  the  last  moment,  rapidly  stirred,  and 
the  metal  poured.  A  piece  of  charcoal  will  be  found  better  for 
making  small  quantities  of  solder  than  a  crucible. 

The  solder  employed  for  uniting  the  various  parts  of  a  piece 
of  dental  mechanism  should  be  sufficiently  fine  to  prevent  it 
from  being  easily  acted  on  by  the  secretions  of  the  mouth. 
Either  of  the  following  recipes  will  be  found  well  adapted  to 
the  purpose: 

FINE-FLOWING    GOLD-SOLDER. 

No.  1.  No.  2. 

22  carat  gold,  .  .          48  grains.  39  grains. 

Fine  silver,    ...         16       "  16       " 

Roset  copper,  .         .         12       "  12       " 

If  pure  gold  is  used,  instead  of  22  carat  gold,  the  solder  will 
be  of  finer  quality,  but  will  not  flow  quite  so  readily.  The  fol- 
lowing makes  rather  finer  solder  than  either  of  the  above;  and, 
although  it  requires  a  little  stronger  blast,  it  flows  very  freely : 

No.  3. — Pure  gold,     .         .         .         .         .6  parts. 
Fine  silver,   .  .  .  .  .     1     " 

Roset  copper,         .         .         ,         .     2     " 

By  adding  one  or  two  grains  of  zinc,  a  solder  may  be  made 
that  will  flow  at  a  lower  temperature  than  those  made  by  the 
foregoing  recipes.  It  will  also  have  a  finer  gold  color,  but  it  is 
apt  to  impart  to  the  piece  a  brassy  taste,  and  for  this  reason  the 
author  rarely  uses  it.  Zinc-solders  are  apt,  not  only  to  have  a 
brassy  taste,  but  also  to  become  brittle  after  long  use. 

Other  recipes  might  be  added,  but  the  foregoing  have  been 
found  with  us  to  answer  every  purpose.  More  difficulty  arises  in 
the  use  of  solders  from  a  wrong  method  of  soldering  than  from 
defect  in  the  solders  themselves.  Almost  every  dentist  will  be 
found  to  have  his  favorite  recipe,  which  "invariably  flows 
smoothly."  The  very  fact  that  so  many  hundred  different  sol- 
ders work  so  well,  goes  far  to  prove  what  we  have  said.  Rules 
for  the  management  of  solder,  plate  and  blow-pipe  in  the  act  of 
soldering,  will  be  hereafter  described. 


CHAPTER    EIGHTH. 

CUPS  AND  MATERIALS  FOR  IMPRESSIONS  OF  THE 
MOUTH— PLASTER  MODELS. 


In  the  construction  of  a  dental  substitute,  mounted  upon  a  plate 
or  base,  it  is  necessary  to  obtain  an  exact  model  of  the  parts  upon 
which  it  is  to  rest,  and  to  which  it  is  to  be  attached.  Before 
this  can  be  done,  a  perfect  impression  of  these  parts  in  some 
soft  arid  yielding  substance  must  be  procured. 

There  are  several  materials  which  may  be  used  for  this  pur- 
pose, each  possessing  certain  advantages  over  the  others.  They 
are:  ivax,  gutta-percha  and  plaster  of  paris ;  to  which  may  be 
added  a  mixture  of  Avax  and  paraffine,  and  a  mixture  of  water 
and  gutta-percha. 

These  materials  must  be  contained  in  a  cup  of  such  size  and 
shape  as  to  permit  easy  introduction  into  the  mouth;  to  be  read- 


FiG.  188. 


Fig.  189. 


ily  held  for  a  few  minutes  in  contact  with  the  parts  to  be  copied; 
and  to  follow,  as  nearly  as  po.ssible,  the  outline  of  these  parts, 
allowing  a  uniform  space  of  one-fourth  or  one-eighth  of  an  inch 


044 


IMPRESSION    CUPS. 


for  the  material.      These   cups  are  known   as   impression-cups, 
mouth-cups,  or  wax-holders. 

Formerly  they  were  made  of  sheet-tin,  cut  into  shape  and  sol- 
dered (Figs.  188  and  189),  and  were  so  very  imperfect,  that  it 
was  often  necessary  to  swage  metallic  cups  to  suit  special  cases. 
The  depots  now  supply  an  excellent  assortment  of  well-shaped 
impression-cups,  of  which  twelve  will  constitute  a  full  assort- 
ment, namely:  three  sizes  for  full  upper  eases  (Fig.  193),  and 

Fig.  190.  Fig.  191. 


I 


three  for  full  lower  (Fig.  190);  three  sizes  for  partial  upper  cases 
(Fig.  188),  (in  these  the  outer  rim  rises  at  a  right-angle);  two 
for  partial  lower  cases  (these  cups  have  a  depression  (Fig.  191) 

Fig.   192. 


Fig.  193. 


Fig    194. 


or  a  place  cut   out  (Fig.  J 92)  to  receive  the  front  teeth);  and  a 
Franklin  cup  (Fig.  194.) 


WAX    AND    GUTTA-PERCHA    IMPRESSIONS.  045 

Besides  these,  every  dentist  should  have  a  supply  of  gutta- 
percha for  making  cups  with  which  to  take  plaster  impressions, 
in  those  cases  where  this  is  the  best,  and  often  the  only,  material 
with  which  it  can  be  done. 

IMPRESSIONS  IN  WAX  AND  GUTTA-PERCHA. 

Wax  was  formerly  the  only  material  used.  It  is,  in  some 
oases,  the  best,  and  is  an  indispensable  material  in  the  labora- 
tory. The  best  kind  of  wax  is  yellow  bees'-wax  from  virgin 
combs.  Commercial  impurities  of  lard  and  corn-meal  injure  its 
properties.  Resin  is  sometimes  used  to  harden  it;  and  white 
wax  is  often  used,  because  harder  than  the  yellow.  A  mixture 
of  paraffine  and  wax  is  preferred  by  some;  but,  perhaps,  the 
best  of  all  mixtures  of  wax  is  the  compound  of  wax  and  gutta- 
percha.    We,  however,  prefer  pure  yellow  wax  to  any  of  these. 

To  prepare  wax  for  impressions:  melt  and  pour  into  cakes 
one-quarter  of  an  inch  thick;  cut  into  pieces  about  two  inches 
-quare;  and  when  nearly  cold,  roll  on  a  wet  board  with  a  wet 
wooden  roller  to  one-half  or  one-fourth  this  thickness.  This 
'ireaks  down  the  crystallization,  and  reduces  it  to  a  form  very 
v.onvenient  for  softening  when  wanted  for  use.  It  may  be  soft- 
ened over  a  broad  flame,  or  before  a  fire  or  stove,  or  in  warm 
water.  In  using  dry  heat,  be  careful  not  to  melt  the  surface  or 
give  the  peculiar  whitish  appearance  that  precedes  melting.  In 
using  water,  have  a  large  quantity,  to  secure  uniformity  of  tem- 
perature, and  keep  it  at  12U°— 130°  Fahrenheit.  Below  this  it 
will  not  yield  readily  to  the  gum ;  above  this  it  becomes  ad- 
hesive. 

Some  practice  is  necessary  in  knowing  the  proper  quantity  of 
wax  to  use  in  the  cup;  the  usual  mistake  is  to  take  too  much. 
Select  a  cup  of  proper  shape  and  size,  and  if  the  arch  is  a  deep 
one,  put  some  hard  wax  or  gutta-percha  in  the  centre,  to  force 
up  the  wax  at  that  point.  This  is  much  better  than  to  have  a 
hole  in  the  cup  through  which  to  make  pressure  with  the  finger. 
Put  the  wax  in  the  cup;  smooth  the  surface,  which  should  be 
a  little  softer  than  the  body  of  the  wax;  then  introduce  and 
press  against  the  gum  or  teeth  with  a  steady,  uniform  and  mode- 
rately strong  pressure,  made,  as  nearly  as  possible,  in  a  direc- 
tion at  right-angles  to  the  plane  of  the  alveolar  ridge. 


646  WAX    AND    GUTTA-PERCHA    IMPRESSIONS. 

The  wax  is  pressed  up  against  the  gums  on  each  side  with  the 
finger,  so  that  an  exact  impression  may  be  obtained  of  all  the 
depressions  and  prominences  on  the  outside  of  the  arch.  On 
the  removal  of  the  cup  and  wax  from  the  mouth,  the  greatest 
precaution  is  necessary  to  prevent  injuring  or  altering  the  shape 
of  the  impression.  Holding  the  handle  firmly,  it  must  be  drawn 
directly  downward;  or,  in  case  there  are  front  teeth,  in  the  di- 
rection of  the  axes  of  these  teeth.  Impressions  of  a  full  upper 
arch  sometimes  adhere  very  tightly;  but  they  can  generally  be 
loosened  by  drawing  up  the  cheek  and  lip  on  one  side  or  both 
sides  alternately.  The  wax  must  be  kept  in  the  mouth  long 
enough  to  cool  and  harden.  A  small  piece  of  ice  in  a  napkin, 
held  against  the  under  side  of  the  cup,  will  rapidly  harden  it. 

It  will  be  found  usually  most  convenient  to  take  the  impres- 
sion of  both  sides  of  the  mouth,  although  the  piece  may  be  re- 
quired only  for  one  side.  But,  if  thought  advisable,  a  half-cup 
(Fig.  189)  may  be  used,  of  which  a  pair  will  be  necessary. 

Dr.  Elliot  recommends  that  the  wax-cup  be  "formed  by  being 
struck  up  between  a  model  and  counter-model,  in  the  same  way 
that  a  gold  plate  is  fitted  to  the  mouth.'"*  "Wax-holders,  thus 
formed,  would,  doubtless,  give,  in  certain  cases,  an  accuracy 
which  would  will  repay  the  extra  trouble.  A  crude  impression 
is  first  taken,  model  made,  and  then  dies  and  counter-dies,  and 
the  plate  (made  of  zinc,  brass,  German-silver  or  silver)  loosely 
fitted.  Very  perfect  wax  impressions  can  be  taken  in  such  cups. 
In  several  cases,  we  have  been  compelled  to  construct  a  wax- 
holder  in  the  manner  described  by  Dr.  Elliot,  Avith  which  we 
readily  succeeded  in  obtaining  a  perfect  impression,  after  having 
previously  made  several  unsuccessful  attempts  to  procure  one 
with  the  ordinary  wax-holder.  This  process,  however,  is  less 
frequently  necessary  than  formerly,  because  of  the  improved 
shape  of  the  cups  now  made  for  sale,  and  which  are  copies  or 
modifications  of  a  series  of  cups  devised  some  years  since  by 
Dr.  J.  A.  Cleaveland,  of  South  Carolina. 

After  removing  the  impression  from  the  mouth,  oil  may  be 
applied  to  it  with  a  camel's-hair  brush,  and,  in  panial  cases,  a 
wire  about  three-fourths  of  an  inch  long  may  be  stuck  into  the 
centre  of  each  cavity  made  in  the  wax  by  those  teeth  which  it 

■•*  American  Journal  of  Dental  Science,  vol.  v,  p.  90. 


WAX    AND    GUTTA  PERCHA    IMPRESSIONS.  647 

is  desirable  to  preserve  unbroken  upon  the  model.  But  if  oil  is 
used  upon  a  wax  or  gutta-percha  impression,  it  must  be  spread 
very  thin.     Many  careful  practitioners  do  not  use  it  at  all. 

Fig.   195. 


The  wax  impression,  prepared  in  this  manner,  will  present  the 
appearance  exhibited  in  Fig.  195.  It  is  scarcely  necessary  to 
add,  that  unless  the  impression  is  perfect,  it  will  be  impossible 
to  fit  a  plate  to  the  parts  of  the  mouth  to  which  it  is  to  be  ap- 
plied with  a  sufficient  degree  of  accuracy  to  be  either  useful  or 
comfortable. 

There  arc  many  cases  in  which  it  is  impossible  to  remove  a 
wax  impression  from  the  mouth  without  injury.  In  such  cases, 
plaster  of  paris  may  be  substituted.  But,  before  describing  this 
process,  we  shall  say  a  few  words  of  gutta-percha  (in  this  word, 
the  ch  is  sounded  soft,  as  in  the  word  perch).  This  exceedingly 
valuable  material  will  be  found  useful  in  taking  impressions  of 
the  lower  jaw,  and  in  some  partial  cases,  also  occasionally  in 
full  upper  cases.  The  manipulations  are:  soften  in  water  heated 
to  180°— 200°  Fahrenheit;  dry  off  the  water;  hold  for  a  few 
moments  over  a  flame,  and  press  into  a  warm  cup ;  keep  the 
fingers  wet,  to  prevent  the  gutta-percha  from  sticking,  but  do 
not  let  water  get  between  it  and  the  cup.  When  the  cup  is 
filled,  place  again  in  Avater  at  180° ;  then  press  it  somewhat 
into  shape  and  introduce  into  the  mouth.  Pressure  must  be 
more  gentle  than  for  wax.  It  must  be  kept  longer  in  the  mouth, 
and  ice  should  be  used  to  cool  it.  Be  very  careful,  in  partial 
cases  where  there  is  much  undercut,  or  a  dovetail  space  between 


648  PLASTER   IMPRESSIONS. 

teeth,  not  to  make  the  gutta-percha  too  hard,  else  it  will  be  al- 
most impossible  to  get  it  out  of  the  mouth. 

Gutta-percha  copies  surfaces  with  the  accuracy  of  plaster; 
but,  although  harder  than  wax,  it  is  more  apt  than  plaster  to 
change  its  shape  upon  withdrawing  it  from  the  mouth.  The 
most  serious  objection  to  its  use  is  its  shrinkage  on  cooling :  a 
fault  which  the  directions  above  given,  for  making  it  adhere  to 
the  cup,  are  designed  to  correct.  The  mixture  of  wax  and  gutta- 
percha combine  some  of  the  valuable  properties  of  both  ma- 
terials. 


PLASTER  IMPRESSIONS. 

Gypsum,  or  sulphate  of  lime,  consists  of  28  parts  lime,  40  of 
sulphuric  acid,  and  18  of  water.  A  beautiful  translucent  variety 
is  known  as  alabaster,  and  the  transparent  crystalline  variety  is 
called  selenite.  That,  however,  used  in  agriculture  and  for  cal- 
cining is  in  amorphous  masses  of  a  grayish  or  bluish  white  color. 
When  exposed  to  a  heat  between  300°  and  400°  Fahr.,  most  of 
the  water  of  the  gypsum  escapes.  It  is  then  known  as  calcined 
plaster,  plaster  of  paris,  or  simply  plaster.  After  being  pro- 
perly calcined  and  pulverized,  if  mixed  with  water  to  the  con- 
sistence of  thin  batter  or  cream,  it  hardens  in  a  few  minutes, 
and  acquires  great  solidity.  The  plaster  has  chemically  reunited 
with  a  portion  of  the  water,  while  another  portion  is  mechani- 
cally held  in  the  porous  mass,  and  may  be  driven  off  by  drying. 
During  the  process  of  consolidation,  it  expands,  in  consequence 
of  the  absorption  of  the  water  by  the  particles  of  plaster.  If 
the  plaster  is  very  fine-grained,  this  absorption  takes  phice 
quickly,  and  the  expansion  occurs  while  the  plaster  is  soft.  But 
coarse-grained  plaster  sets  before  the  pa.  tides  become  thoroughly 
saturated;  hence  it  continues  to  expand,  more  or  less,  for  some 
time  after  solidification.  There  is  a  great  difference  in  the 
quality  of  plaster  of  paris.  That  used  for  taking  impressions 
of  the  mouth  (and,  in  fact,  for  all  dental  purposes)  should  be  of 
the  best  description,  well  calcined,  finely  pulverized,  and  passed 
through  a  sieve  previously  to  being  used.  The  idea  of  taking 
impressions  for  full  sets  of  teeth  with  plaster  of  paris  originated, 
we  believe,  almost  simultaneously  with  Drs.  Westcott,  Dunning 


It 


PLASTER    IMPRESSIONS.  649 

and  Bridges.  Within  the  past  four  years  Professor  Austen  has 
perfected  a  method  of  using  it  in  connection  with  gutta-percha 
cups,  which  makes  it,  in  the  hands  of  a  careful  manipulator, 
universally  applicable  to  every  case  in  which  a  dental  appliance 
is  called  for. 

For  plaster  impressions  in  ordinary  full  cases,  upper  or  lower, 
select  a  brittania  cup  about  one-eighth  of  an  inch  larger  than 
the  alveolar  ridge,  and,  in  case  of  a  deep  upper  arch,  build  up 
with  wax,  so  as  to  give  support  to  the  soft  plaster;  also  supply 
with  wax  any  deficiency  in  the  size  of  the  cup  at  the  back  part 
or  around  the  outside  edge. 

For  special  full  cases,  and  for  all  partial  cases.  Professor 
Austen  recommends  a  gutta-percha  cup  made  thus :  Take  a  wax 
impression,  and  make  a  model ;  in  partial  cases,  brush  over  the 
teeth  of  the  model  one  or  two  layers  of  thin  plaster,  to  fill  up  all 
undercuts,  and  to  make  the  plate  fit  loosely ;  saturate  the  model 
with  water  and  mould  over  it  a  gutta-percha  cup ;  it  should  be,  on 
tue  inside,  from  one-fourth  to  one-half  of  an  inch  thick,  so  as 
to  be  stiff  and  unyielding,  but  on  the  outside  not  more  than  one- 
eighth  or  one-sixteenth  thick,  so  as  to  be  slightly  elastic  and 
yielding.  The  whole  inside  of  the  cup  must  be  roughened  up  with 
a  scaler  or  excavator  in  such  a  way  that  the  plaster  can  take  firm 
hold.  In  most  partial  cases,  the  impression  must  be  removed 
in  sections,  the  inside  remaining  entire,  but  the  outside  and  the 
parts  between  the  teeth  coming  away  separately.  In  very  diffi- 
cult cases,  it  is  necessary  to  partially  cut  through  the  cup  so  as 
to  permit  its  removal  in  sections  with  the  plaster  adherent. 
These  cups  have  no  handle,  but  are  removed  by  inserting  a  plug- 
ging instrument  into  a  small  hole  previously  made  in  the  back 
part  of  the  cup  where  it  is  thickest. 

To  take  a  plaster  impression,  place  the  patient  in  a  common 
chair,  and  after  the  cup  is  introduced,  incline  the  head  forward, 
holding  it  in  place  with  a  gentle  but  steady  pressure  upon  the 
centre  of  the  cup.  The  plaster  should  be  very  fine-grained,  and 
mixed  rather  thin,  to  get  rid  of  air-bubbles.  If  necessary, 
a  little  salt  or  sulphate  of  potash  should  be  added  to  quicken 
slow-setting  plaster.  If  made  to  set  too  rapidly,  it  hurries  the 
operator  too  much  and  increases  the  risk  of  failure ;  if  it  sets 
too  slowly,  both  patient  and  operator  become  wearied  before  it 
42 


650  PLASTER   IMPRESSIONS. 

it  is  hard  enough  to  remove.  It  should  require  about  four  mi- 
nutes to  harden  after  it  is  introduced  into  the  mouth,  which 
must  be  done  when  it  is  stiff  enough  to  allow  the  plaster  to  be 
moulded  into  some  shape,  and  yet  soft  enough  to  permit  no  sharp 
points  or  angles  on  its  surface. 

The  hardness  of  plaster  in  the  mouth  can  be  ascertained  by 
timing  it,  when  the  exact  time  required  for  setting  is  known;  or 
by  testing  some  of  the  phister  remaining  in  the  bowl.  As  soon 
as  it  breaks  with  a  sharp  fracture,  it  should  be  removed.  To 
keep  it  in  much  longer  than  this  is  apt  to  give  unnecessary  pain 
and  diflficulty  in  removal,  owing  to  the  absorbing  property  of  the 
hardened  plaster,  which  causes  it  to  cling  with  great  tenacity  to 
the  mucous  membrane. 

Full  lower  impressions  are  generally  easy  to  withdraw;  but 
some  full  upper  ones  adhere  very  tenaciously.  Raising  the 
cheek  on  one  side  or  in  front  and  depressing  the  cup,  will  detach 
most  cases.  This  can  be  done,  in  case  of  plaster,  without  risk 
of  injuring  the  shape  of  the  impression.  Where  there  is  much 
undercut,  the  plaster  will  break ;  but  it  can  readily  be  replaced. 
Sometimes  the  action  of  the  cheeks  and  lips,  or  of  the  soft 
palate,  will  loosen  the  impression;  or  an  instrument  may  be 
used  to  press  up  the  palate,  and  thus  cause  air  to  pass  in  at  the 
back,  when  it  may  be  easily  removed. 

In  partial  cases,  the  outer  rim  (which  for  this  purpose  is  made 
elastic,  or  else  in  sections)  is  first  detached,  and  the  central  por- 
tion then  loosened  by  an  instrument  inserted  into  the  hack  part 
of  the  gutta-percha  cup.  If  there  should  be  many  broken,  de- 
tached fragments,  either  loose  or  caught  in  dovetail  spaces  be- 
tween teeth,  these  must  be  very  carefully  removed;  and  when 
the  surface-moisture  has  dried  off,  they  must,  with  utmost  nicety, 
be  replaced  in  the  impression.  This  is  sometimes  a  tedious  and 
diflBcult  operation ;  but  it  is  not  trouble  misapplied,  since  it  is 
the  only  way  in  which  perfect  impressions  of  difficult  partial 
cases  can  be  obtained.  The  fragments  being  all  adjusted  and 
the  outside  ones  secured  by  a  little  resinous  cement,  prepare  the 
surface  as  in  full  sets  for  preventing  the  plaster  of  the  model 
from  adherinir. 

Wax  and  gutta-percha  impressions  require  nothing  for  this 
purpose,  or,  at  most,  a  very  thin  layer  of  oil.     Plaster  impres- 


PLASTER    MODELS.  651 

sions  may  be  rendered  separable  :  1.  By  a  varnish  of  sandarach  or 
shel-lac,  or  of  dilute  soluble  glass,  with  a  little  oil  upon  the  var- 
nished surface  when  dry ;  2.  by  saturating  it  with  as  much  oil 
as  it  will  take  up  Avithout  standing  upon  its  surface ;  3.  by  coat- 
ing the  surface  with  a  dilute  soap  mixture.  The  first  is  best  ap- 
plied with  a  small  bristle-brush;  the  latter  with  a  camel's-hair 
brush  or  a  stiff,  pointed  feather.  The  varnish  must  be  kept  well 
stopped,  or  from  time  to  time  diluted,  so  as  not  to  become  thick. 
The  soap-mixture  needs  occasional  renewal,  as  the  plaster  grad- 
ually neutralizes  its  oil  and  renders  it  unfit  for  use. 

The  method  of  obtaining  a  transfer  of  the  alveolar  ridge  re- 
commended by  M.  Desirabode  will,  with  proper  care,  secure  a 
tolerably  accurate  result.  It  consists,  after  having  obtained  a 
metallic  model  and  counter-model,  in  striking  up  a  lead  plate, 
trimming  it  to  the  proper  size,  and  adjusting  it  with  the  finger 
to  the  alveolar  border  and  palatine  arch  until  it  is  made  to  fit 
every  part  with  perfect  accuracy.  It  is  then  carefully  removed, 
and  used,  instead  of  the  original  wax  impression,  for  the  pro- 
curement of  a  second  plaster  model.  From  this  last,  new  me- 
tallic castings  are  obtained,  by  means  of  which  a  plate  may  be 
made.  This  was,  doubtless,  an  improvement  upon  some  of  the 
older  methods  of  taking  impressions :  but  it  is  certainly  inferior 
in  accuracy  to  the  present  methods  with  more  modern  appliances. 

PLASTER   MODELS. 

After  the  impression  has  been  thus  prepared,  it  is  then  filled 
with  a  thin  paste  or  batter  made  of  the  best  calcined  plaster  of 
paris  and  water.  This  is  at  first  poured  in  while  quite  thin,  and 
with  great  care,  until  the  impressions  made  by  the  teeth,  if  there 
are  any  remaining  in  the  jaw,  are  filled;  after  which,  the  batter 
may  be  allowed  to  thicken  a  little  before  the  remainder  of  the 
impression  is  filled.  It  is  then  poured  on  until  the  plaster  is 
raised  an  inch  or  an  inch  and  a  half  above  the  impression.  A 
camel's-hair  brush,  or  a  feather  from  the  wing  of  poultry  or 
game,  will  be  found  very  useful  in  spreading  the  plaster  over 
the  surface  of  the  impression. 

After  the  plaster  has  sufficiently  hardened,  it  may  be  trimmed 
and  removed  from  the  impression.     This  is  done,  in  the  case  of 


652  PLASTER    MODELS. 

wax  and  gutta-percha,  by  softening  in  water,  being  careful  to 
make  it  so  soft  in  partial  cases,  or  when  the  ridge  is  thin,  as  not 
to  break  off  any  of  the  teeth  or  ridge.  Plaster  impressions 
may,  in  simple  cases,  be  loosened  by  striking  the  back  with  the 
plaster-knife  hamlle  and  removing  entire.  But  in  partial  cases, 
and  in  undercut  full  cases,  the  cup  must  first  be  removed  (by 
hot  water,  if  of  gutta-percha),  and  the  impression  then  carefully 
detached  in  fragments.  The  same  impression  can  sometimes  be 
used  a  second  or  third  time;  but  usually  the  shape  of  it  is  so 
altered  in  the  removal  of  the  model,  that  a  duplicate  impression 
is  necessary  if  more  than  one  model  is  wanted.  The  model  may 
then  be  shaped  with  a  knife,  until  it  presents  an  appearance 
something  like  that  represented  in  Fig.  196,  having  a  slight  flare 

Fig.  196. 


or  taper,  so  as  to  admit  of  easy  withdrawal  when  used  in  sand- 
moulding.  This  flare  can  be  given  by  surrounding  the  impres- 
sion with  a  tapering  tin  ring,  more  regularly  than  it  can  be 
trimmed  with  a  knife. 

The  body  of  the  model  may  be  made  in  several  ways :  1,  by 
using  the  tin  rings,  as  just  stated,  which  is  the  best  for  deep 
models  used  in  moulding;  2,  by  surrounding  the  impression  with 
sheet-wax,  waxed  cloth,  sheet-lead  or  tin-foil;  3,  by  filling  the 
impression,  then  inverting  it  upon  a  mass  of  soft  plaster  built 
upon  the  table  to  the  required  height.  The  last  is,  perhaps,  the 
most  convenient  method,  except  for  cheoplastic  models  and  deep 
models  used  in  sand-moulding.     Models  for  vulcanite  work  need 


PLASTER    MODELS. 


653 


no  particular  shaping,  as  they  are  subsequently  to  be  set  into 
flasks.  These  should  be  made  no  deeper  than  is  requisite  for 
strength  and  they  must  not  be  varnished,  unless  it  be  with  dilute 
soluble  glass.  Models  from  which  the  counter-die  is  made  by 
dipping  in  lead,  &c.,  need  no  special  shaping,  but  must  be  thick 
enough  to  be  conveniently  held  with  the  fingers  whilst  being 
dipped.  No  models  should  be  varnished  which  are  to  have 
melted  metal  brought  in  contact  with  them. 

In  sand-moulding  we  may  use  a  deep  model  or  a  very  shallow 
one.  The  process  with  the  latter  will  be  hereafter  described. 
In  using  the  former,  modifications  of  shape  are  sometimes  called 
for  to  overcome  difficulties  arising  from  undercutting  on  the 
outside  of  the  upper  ridge  and  on  the  inside  of  the  lower.  These 
may  be  overcome:  1,  by  filling  up  the  undercut  with  wax  or 
plaster  in  all  places  where  it  is  unnecessary  or  impracticable  to 
carry  the  metallic  plate;  2,  by  using  a  peculiarly-constructed 
flask  for  moulding,  such  as  the  one  invented  by  Dr.  G.  E.  Ilawes 
(Figs.  201,  202);  3,  by  making  a  sectional  model  (Figs.  197, 
198).  (This  method  was  first  introduced,  we  believe,  by  Dr.  A. 
Westcott,  and  is  best  made  by  filling  the  central  third  of  the 
wax  impression  with  the  plaster,  keeping  it  from  the  lateral 
thirds  by  a  temporary  use  of  clay  or  putty.  This  is  then  re- 
moved and  trimmed,  leavins:  the  lower  surface  Avider   than  the 

Fig.  197. 


upper  (Fig.  197).     This  done,  it  is  replaced  in  the  impression, 
and  filled  up  on  each  side  with  plaster ;  the  model  is  then  re- 


654 


PLASTER    MODELS. 


moved,  properly  trimmed,  and  varnished,  when  it  presents  the 
appearance  represented  in  Fig.  198) ;  4,  by  filling  the  undercut 

Fig.  198. 


with  movable  pieces  of  plaster,  technically  known  as  false 
cores,  first  practiced  by  Professor  Austen.  In  making  the  false 
cores,  they  should  be  shaped  so  as  to  admit  of  being  "drawn" 
from  the  sand.  At  the  same  time,  they  must  have  a  decided 
angle,  so  as  to  mark  distinctly  the  place  in  the  sand  for  their 
replacement.  A  small  nail  or  tack  in  the  sand  above  the  core 
will  keep  it  in  place  whilst  the  metal  is  being  poured. 

For  striking   up  a   plate  with  the   outer   edge   turned   up,  a 
flange,  about  an  eighth  of  an   inch  wide,  is  formed  around  the 
Pic  199  outside    of   the    plaster   model, 

Avhere  it  is  designed  that  the 
edge  of  the  base  shall  terminate 
on  the  alveolar  border.  It  may 
be  shaped  either  in  wax  or  plas- 
ter, and  should  stand  off  from 
the  ridge  at  an  angle  of  about 
90°  or  100°,  the  curvature  of 
the  rim  being  completed  with 
pliers  after  swaging.  A  plaster 
model  of  the  upper  jaw  thus 
prepared  is  represented  in  Fig. 
199.  A  plate,  swaged  with  such 
a    rim    i.s   only  used  for  mounting    gum  or  block  teeth;    it  is 


PLASTER    MODELS.  655 

stronger  than  a  simple  plate  and  is  susceptible  of  a  more  beauti- 
ful finish.  For  a  lower  set  of  block  teeth,  the  edge  of  the  plate 
may  also  be  turned  up  all  the  waj  round.  But  the  rim  may  be 
made  of  a  separate  narrow  strip  of  gold,  soldered  to  the  outer 
edge  of  the  plate  in  such  a  manner  as  to  cover  the  outer  surface 
of  the  extremities  of  the  teeth  or  edge  of  the  blocks  near  the 
base,  which  is,  perhaps,  on  some  accounts,  preferable  to  a  plate 
with  a  turned  edge.  The  details  of  this  latter  method  wuU  be 
described  in  the  chapter  on  Porcelain  Block  Teeth. 

The  model,  after  being  trimmed,  should  (if  dies  are  to  be 
made  from  it  by  the  process  of  sand-moulding)  have  several 
coats  of  shel-lac  or  sandarach  varnish  applied  to  it  with  a  small 
bristle-brush,  to  give  it  a  smooth,  hard  and  polished  surface. 
This  will  prevent  it  from  wearing  away  by  use,  and  render  it 
more  pleasant  to  the  touch  of  the  hand.  The  sandarach  varnish 
is  preferable  to  the  shel-lac,  as  it  is  harder ;  it  is  also  more  trans- 
parent, and  consequently,  does  not  color  the  plaster.  It  may 
be  made  in  the  following  manner :  Take  six  ounces  of  gum-san- 
darach,  one  ounce  of  elemi,  digest  in  one  quart  of  alcohol,  mode- 
rately warm,  until  dissolved,  then  add  two  ounces  of  Venice 
turpentine.  This  is,  perhaps,  as  good  a  varnish  as  can  be  used 
for  plaster  models.  It  is  easily  prepared ;  but  the  alcohol  should 
be  warmed  in  a  sand-bath  or  hot  water,  to  prevent  it  from  taking 
fire.  To  make  the  finest  varnish,  the  sandarach  should  be  of 
the  most  transparent  quality,  and  washed  in  Avater  before  being 
put  into  the  alcohol. 


CHAPTER    NINTH. 

METALLIC  DIES  AND  COUNTER-DIES— SWAGING  PLATES. 

Various  methods  have  heen  adopted  for  procuring  metallic 
dies  and  counter-dies.  The  three  following  are  all  which  the 
author  deems  it  necessary  to  describe :  The  first  of  these 
consists  in  pouring  melted  metal  into  a  mould  or  matrix  made 
in  sand  with  the  plaster  model.  By  this  means  the  die  is  formed, 
and  the  counter-die  is  obtained  either  by  immersing  this  in,  or 
pouring  melted  metal  upon  it.  The  second  consists  in  making 
the  counter-die  first,  either  by  immersing  the  plaster  model  in, 
or  pouring  melted  metal  upon  it,  and  afterward  obtaining  the 
die  by  pouring  melted  metal  in  this.  The  third  consists  in 
pouring  the  metal,  for  the  metallic  die,  directly  into  the  impres- 
sion. A  very  ingenious  and  admirable  set  of  flasks  for  this 
purpose  have  been  invented  by  Dr.  F.  Y.  Clark,  of  Savannah, 
and  are  kept  for  sale,  we  believe,  by  Dr.  S.  S.  White.  If  the 
impression  is  thoroughly  dried,  the  first  metallic  die  will  be  per- 
fect, no  matter  how  much  undercut  there  may  be.  A  second  or 
third  may  then  be  taken,  more  or  less  defective,  but  very  useful 
for  the  first  stages  of  the  swaging  process.  Zinc  is  the  metal 
used  by  Dr.  Clark  for  the  die. 

The  SECOND  method  admits  of  three  modifications — 1.  The 
fusible  metal  process.  In  this  the  model  is  surrounded  with  thick 
paper,  and  fusible  metal  in  a  semi-fluid  state  is  dashed  over  it 
with  a  spoon,  the  model  being  cold,  so  as  to  rapidly  chill  the 
metal.  While  still  warm,  the  paper  is  removed  and  the  counter- 
die  trimmed  with  a  knife,  for  at  this  temperature  it  can  be  cut 
as  readily  as  cheese.  The  counter-die,  when  cold,  is  then  smoked 
or  coated  with  whiting,  surrounded  with  paper,  and  more  semi-fluid 
fusible  metal  dashed  on  it,  to  make  the  die;  which  process  is 
repeated  until  two  or  six  dies  are  made,  according  to  the  irregu- 
larity of  the  case. 

2.  The  dipping  process,   which  consists   in   pouring   melted 


METALLIC    DIES    AND    COUNTER-DIES.  657 

lead,  type-metal  or  pewter  into  a  sheet  or  cast-iron  cup  or  box, 
three  and  a  half  or  four  inches  in  diameter,  and  three  inches 
deep,  until  it  is  half  full;  then  stirring  the  fluid  mass  with 
gradually  increasing  rapidity  until  it  begins  to  granulate,  and 
immediately  immersing  so  much  of  the  plaster  model  as  the 
plate  is  designed  to  cover,  and  holding  it  there  until  the  metal 
congeals.  It  is  then  removed,  and  the  whole  upper  surface  of 
the  counter-die  covered  with  a  thin  coating  of  whiting  or  lamp- 
smoke  in  the  manner  before  directed.  After  this  has  become 
perfectly  dry,  melted  block-tin,  type-metal  or  soft  solder,  at  a 
temperature  so  low  that  it  will  not  char,  or  even  discolor  white 
paper,  may  be  poured  on,  until  the  cup  or  box  is  filled.  When 
cold,  the  castings  are  removed  from  the  iron  cup  or  box,  separa- 
ted, and  are  then  ready  for  use. 

3.  Br.  Crunning's  method,  in  which  a  very  thin  model  (made 
of  plaster  two  parts,  and  sand  or  feld-spar  one  part)  is  placed 
in  the  bottom  of  an  iron  box,  three  and  a  half  to  four  inches  in 
diameter  and  about  two  inches  deep.  It  is  fastened  there  by  a 
thin  layer  of  plaster  and  sand,  then  thoroughly  dried  by  raising 
box  and  all  gradually  to  the  temperature  of  the  melted  metal, 
which  is  next  poured  in,  and  the  box  set  in  a  shallow  vessel  of 
water  to  cool  it  rapidly  from  the  outside.  To  delay  the  cooling 
in  the  centre  until  the  last  moment,  and  so  prevent  contraction 
at  that  place,  a  very  hot  pointed  iron,  somewhat  similar  in  shape 
and  size  to  a  tinner's  soldering-iron,  is  placed  upon  the  centre 
of  the  model  before  the  metal  is  poured.  When  cold,  this  is 
removed  and  the  conical  space  filled  with  metal.  The  counter- 
die  is  thus  made  of  lead,  alloyed  with  tin  or  type-metal.  The 
die  is  made  by  placing  over  this  a  stout  WTOught-iron  ring  and 
pouring  in  fusible  metal.  Dr.  Gunning  uses  from  three  to  eight 
dies,  according  to  the  sharpness  of  the  prominences  of  the  model. 
The  method  gives,  in  his  hands,  very  accurately  fitting  plates. 

When  metallic  dies  are  to.  be  obtained  by  the  first  method,  a 
moulding-box  of  wood  is  required,  about  six  inches  square  and 
three  or  four  inches  deep.  This  is  to  be  filled  with  fine  sand, 
such  as  is  used  in  brass  and  iron  foundries,  in  the  following 
manner :  The  deep  or  shallow  plaster  model  is  placed  on  the 
moulding-table  exactly  in  the  centre  of  the  box,  with  its  face 
upward.     Sand  is  then  firmly  packed  around  the  sides  of  the 


658  METALLIC    DIES    AND    COUNTER-DIES. 

model.  Sand  covering  the  face  of  the  model  should  then  be 
nifted  on  to  the  depth  of  a  half  inch,  the  box  then  filled,  and 
the  whole  rammed  with  a  firmness  proportioned  to  the  coarse- 
ness or  dryness  of  the  sand — damp  or  very  fine  or  strong  {i.e., 
with  large  per  centage  of  clay)  sand  not  permitting  so  much 
compression  as  sand  possessing  the  opposite  qualities,  because 
it  would  become  too  compact  to  permit  the  escape  of  the  vapors 
formed  during  the  process  of  pouring. 

The  box  is  then  turned  over  and  gently  tapped  several  times 
with  some  light  instrument  or  hammer,  for  the  purpose  of  start- 
ing or  detaching  it  a  little  from  the  matrix,  and  then  carefully 
removed.  If  the  model  be  composed  of  three  pieces,  the  middle 
section  is  first  removed,  and  afterward  the  two  others.  There 
are  two  ways  of  drawing  the  model :  first,  by  screwing  into  it 
an  excavator  or  gimlet,  and  carefully  drawing  it  out;  second,  by 
throwing  it  out  with  a  dexterous  jerk  of  the  matrix. 

If  the  deep  model  is  used,  the  matrix  is  now  ready  for  poui'- 
ing,  after  removing  all  loose  sand  and  making  a  groove  at  the 
back  part  of  the  matrix  to  receive  the  first  flow  of  the  metal. 
But  if  the  thin  model  is  used,  a  ring  must  be  set  upon  the  sand 
after  the  model  is  removed,  to  give  the  additional  size  which  the 
die  requires  to  prevent  cracking  under  the  swaging-hammer. 

The  mould  being  prepared,  the  metal  to  be  employed  for  the 
casting  should  be  put  in  a  tolerable  thick  wrought  or  cast-iron 
ladle,  and  melted  in  a  common  fire  or  furnace.  If  brass  is  used, 
the  latter  will  be  required  to  melt  it ;  but  if  zinc,  block-tin  or 
lead,  a  common  fire  will  afford  sufficient  heat.  After  the  metal 
has  become  thoroughly  melted,  it  is  poured  into  the  furrow 
formed  in  the  sand,  whence  it  will  immediately  flow  into  the 
back  part  of  the  mould.  It  is  necessary  to  convey  the  melted 
metal  into  the  mould  in  this  way  to  prevent  the  liability  to  in- 
jury which  it  might  sustain  by  pouring  directly  into  it. 

There  have  been  quite  a  number  of  moulding-flasks  devised 
to  supersede  the  wooden  one  just  described,  or  the  common  cart- 
wheel box  which  was  once  much  used.  Some  of  these  are  worse 
than  useless;  others  arc  very  convenient,  and  have  the  advan- 
tage of  requiring  a  small  quantity  of  sand,  also  of  permitting 
the  sand  to  be  dried,  which  cannot  be  well  done  in  the  wooden 
box.     The  simplest,  and  perhaps  best,  flask  is  one  recently  fur- 


METALLIC    DIES    AND    COUNTER-DIES. 


659 


nished  to  the  profession  by  Dr.  S.  S.  White,  from  patterns  fur- 
nished by  Dr.  E.  N.  Bailey.  Fig.  200  represents  the  shape  and 
working  of  this  flask. 

Fig.  200. 
A  15  C 


Half-flask  B  is  placed,  joint-edge  downward,  over  a  thin  model, 
and  firmly  packed  with  sand;  then  turned  over  and  the  sand 
trimmed  nearly  to  where  the  plate  comes  on  the  ridge ;  this 
makes  it  easy  to  draw.  Next  pour  zinc  into  the  mould,  and  at 
once  place  on  half-flask  A  and  complete  the  pouring.  When 
cool,  remove  the  sand,  invert  the  flask,  with  zinc  die  contained, 
and  pour  the  lead  (C)  upon  the  zinc  for  the  counter-die. 

In  cases  of  moderate  undercut  in  front,  the  tJiin  model  can 
generally  be  drawn  by  a  dexterous  backward  movement.  But 
for  a  deeper  undercut  in  front,  and  also  at  the  side,  the  mould- 
ing-flask of  Dr.  Hawes  (Figs.  201,  202,  203)  will  be  found  very 
useful. 

The  manner  of  using  it  is  thus  described  by  Dr.  C.  C.  Allen ; 
"If  the  model  be  considerably  smaller  than  the  space  between 
Fig.  201.  Fig.  203. 


Fig.  202. 

Fio.    201.  The  lower  section  of  ihe  flask,  slightly 

opened  to  show  joiats.     Fia.  202.  The  upper  section. 

Flo.  203.  The  lower  section  closed,  and  confined  by  a 

pin,  with  the  plaster  model  placed  in  it. 

the  flanges  projecting   inward,  small 
slips  of  paper  may  be  placed  in  the 
joint   extending   to  the  sides  of  the 
model,  so  as  to  part  the  sand  when   opening   the  flask,  for  the 


660 


METALLIC    DIES   AND    COUNTER-DIES. 


removal  of  the  pattern.  The  sand  may  now  be  packed  around 
the  model  up  to  the  most  prominent  part  of  the  ridge.  It  should 
be  finished  smoothly  around  it,  slightly  descending  toward  the 
model,  so  as  to  form  a  thick  edge  of  sand  for  the  more  perfect 
parting  of  the  flask.  The  sand  and  face  of  the  model  must 
now  be  covered  with  dry  pulverized  charcoal,  sifted  evenly  over 
the  whole  surface.  When  this  is  done,  the  upper  section  of  the 
flask  is  placed  over  the  lower,  and  carefully  filled  with  sand.  It 
is  then  raised  from  the  lower  one,  which  may  now  be  parted  by 
removing  the  long  pin,  and  the  model  gently  taken  away.  When 
closed,  and  the  two  put  together  again  and  inverted,  it  is  ready 
to  receive  the  melted  metal."  After  the  metal  has  cooled,  it 
may  be  removed,  and  turned  over,  so  that  the  face  of  the  die 
shall  be  upward,  while  the  remainder  is  buried  in  the  sand. 
Thus  placed,  it  is  encircled  with  the  ring  (Fig.  202),  and  the 
metal  for  the  counter-die  poured  upon  it. 

The  metals  most  commonly  used,  when  metallic  dies  are  made 
by  sand-moulding,  are  zinc  and  lead.  For  many  reasons,  these 
are,  perhaps,  the  best  metals  for  general  use  that  can  be  em- 
ployed. Zinc  is  the  hardest  metal  that  the  dentist  can  conve- 
niently melt.  Its  shrinkage  is  objectionable  in  case  of  deep  or 
large  arches,  and  for  mouths  where  the  mucous  membrane  is 
very  hard.  In  such  cases,  a  finishing  die  may  be  made  of  block- 
tin,  type-metal,  soft  solder,  or  Babbit's-metal  (a  patented  alloy 
of  copper,  tin  and  antimony,  which  can  be  obtained  at  any  ma- 
chine-shop), which  last  is  nearly  as  hard  as  zinc,  but  has  de- 
cidedly less  shrinkage.  When  a  metal  softer  than  zinc  is  used, 
several  dies  will  be  necessary  to  complete  the  swaging. 

A  counter-die,  however,  should  be  soft.  Lead  is,  perhaps, 
the  best  metal  that  can  be  used ;  but  tin  is  not  too  hard  if  the 
die  is  made  of  zinc.  It  is  desirable,  if  practicable,  that  the 
metal  last  poured  (in  the  case  of  sand-moulding,  this  is  the 
counter-die)  should  melt  at  a  lower  temperature  than  the  other. 
In  this  respect,  zinc  and  lead  are  admirably  suited — zinc  melting 
at  770°,  and  lead  at  600°. 

But  in  all  cases  of  melting,  it  is  a  safe  rule  to  pour  the  metals 
at  the  lowest  temperature  at  which  they  will  flow.  It  is  prudent, 
also,  to  coat  the  metal,  on  which  other  metal  is  poured,  with  a 
mixture  of  alcohol  and  whiting,  to  prevent  all  chance  of  adhe- 


SWAGING    PLATES.  661 

sion.  One  more  very  important  caution  in  the  melting  of  zinc 
and  lead  is,  invariably  to  use  separate  ladles. 

The  elastic  vapor  generated  by  the  contact  of  the  water  in 
the  sand  with  the  hot  metal  sometimes  collects  under  or  rises 
through  the  metal,  and  renders  the  casting  more  or  less  imper- 
fect. This  may  be  prevented — 1,  by  drying  the  sand;  2,  by 
using  coarse  or  loosely-packed  sand,  and  avoiding  too  much 
moisture ;  3,  by  mixing  the  sand  with  oil,  instead  of  water.  The 
slightest  moisture  on  one  metal  previous  to  the  pouring  of  an- 
other metal  upon  it,  will  make  the  latter  imperfect.  When  the 
last  metal  has  cooled,  the  castings  may  be  separated,  and,  if 
perfect,  are  then  ready  for  use. 

In  making  metallic  dies  for  partial  cases,  about  three-fourths 
of  the  crowns  of  the  teeth  should  be  cut  from  the  plaster  model 
before  using  it  for  moulding.  The  plate  can  thus  be  fitted  more 
easily  and  perfectly  than  can  be  done  when  the  teeth  remain  on 
the  plaster  model  and  zinc  die;  for,  in  the  former  case,  the 
plate  need  not  be  cut  to  fit  the  teeth  until  it  has  been  swaged; 
while  in  the  latter,  this  must  be  done  first,  and,  consequently, 
in  striking  it  up,  it  will  be  drawn  to  a  greater  or  less  distance 
away  from  them.  There  is  also  danger  of  splitting  the  plate, 
in  swaging  it  into  the  spaces  between  the  teeth,  if  these  are  left 
on  the  metallic  die. 

SWAGING  PLATES. 

A  die  and  counter-die  having  been  obtained,  a  piece  of  sheet- 
lead  is  adapted  to  the  alveolar  ridge,  and  the  dimensions  of  the 
plate  marked  upon  it  with  a  pointed  instrument.  Paper  is  some- 
times used  for  this  purpose,  but  is  not  so  good  as  thin  sheet-lead 
or  heavy  tin  foil.  The  pattern  thus  marked  is  cut  out,  laid 
upon  a  piece  of  gold  plate  of  the  right  thickness,  and  its  size 
and  shape  marked  upon  it.  The  plate  should  be  cut  a  little  too 
large,  to  allow  for  trimming  and  any  accidental  slipping  upon 
the  die.  In  partial  cases,  the  pattern  should  be  carried  partly 
over  the  excised  teeth,  and  no  attempt  made  to  fit  it  accurately 
around  the  necks  of  the  teeth  until  the  swaging  is  nearly  or 
quite  completed.     With  a  pair  of  strong  shears  or  snips  (Figs. 


602 


SWAGING    PLATES. 


204,  205,)  the  portion  of  plate  thus  marked  is  cut  out.    Fig.  204 

Fig.  204. 


Fig.  205. 


represents  a  pair  of  Stubbs'  plate  shears:  Fig.  205,  a  pair  of 
different  construction,  with  longer  and  more  conveniently  shaped 

handles.  The  blades  of  some 
shears  are  curved  laterally;  but 
this  form  is  not  desirable.  For 
curves  which  the  straight  shears 
will  not  cut,  a  fine  watch  spring 
saw  may  be  used ;  and  for  very 
short  curves,  around  teeth  for 
instance,  a  pair  of  cutting  forceps  shaped  as  in  Fig.  206. 

The  plate  must  next  be  well  annealed  and  partially  fitted,  by 

Fig.  206. 


wooden,  horn,  or  soft-metal  hammers,  to  tlie  part  of  the  die 
inside  the  ridge.  The  swaging  is  continued  by  the  use  oi partial 
counter-dies,  which  are  made  by  placing  a  rim  of  clay  or  putty 
around  the  ridge  and  back  part  of  the  metallic  die,  and  pouring 
on  it  fusible  metal.  In  this  way  the  plate  is  to  be  perfectly 
fitted  as  far  as  the  ridge.  Then  clamping  the  plate  between  the 
die  and  the  partial  counter,  the  edge  is  to  be  gradually  carried 
over  the  top  and  outside  of  the  ridge  with  hammers  and  small 
wooden  or  ivory  stakes.     The  plate  may  be  clamped  in  a  vise, 


SWAGING    PLATES. 


663 


or  by  means  of  a  string  passing  over  the  die  and  under  the  foot: 
but  a  more  convenient  and  eifective  method  is  found  in  the  use 
of  Dr.  T.  H.  Burras's  clamps,  Fig.  207.  Of  the  two  forms 
here  given,  the  sliding  arm  (No.  2)  is  preferable  to  the  long 

Fig.  207. 


No.  1. 


5o.  2. 


screw  (No.  1).  The  application  of  the  clamp  is  so  plainly  shown 
in  No.  1,  that  any  description  is  unnecessary. 

It  is  the  practice  of  some  to  cut  out  V  shaped  pieces  from  the 
front  or  back  part  of  the  plate,  to  prevent  the  plaiting  of  the 
metal.  This  is  bad  practice,  and  is  never  called  for,  if  proper 
care  is  used  in  swaging,  and  the  metal  is  of  proper  fineness. 
To  avoid  plaits  or  folds,  anneal  often,  and  in  deep  arches  carry 
the  plate  down  very  gradually;  also  take  care  in  such  cases  that 
the  plate  be  thick,  to  allow  for  stretching  or  drawing.  In  swag- 
ing over  the  ridge  it  is  a  very  common  mistake  to  hammer  down 
the  outside  before  fully  striking  up  (with  hammer  and  stakes) 
the  parts  nearest  the  partial  counter-die.  Always  make  it  a 
rule,  in  carrying  over  the  ridge,  to  swage  from  the  centre  out- 
ward, carrying  the  plate  "  home"  as  you  proceed. 

Professor  Austen  regards  all  forms  of  bending  forceps  as  worse 
than  useless.  They  bruise  the  plate,  as  will  any  steel  or  hard 
metal  instruments.     There  is  no  shape  of  arch  or  of  plate  which, 


664  SWAGING    PLATES.  j 

by  the  above  simple  process,  cannot  be  perfectly  fitted  with  a 
20-carat  plate. 

The  plate  having  been  thus  almost  fitted  by  hammers  and 
partial  counters,  it  should  be  trimmed  to  its  exact  shape,  and 
then  placed  between  a  fresh  die  and  the  full  counter-die,  and 
carried  "home"  by  several  firm  blows  of  the  hammer,  given 
directly  upon  the  centre  of  the  die.  The  hammer  should  not 
weigh  more  than  three  pounds,  with  a  handle  about  a  foot  long. 
It  is  a  great  mistake  to  use  a  very  heavy  or  a  very  long  handled 
hammer.  The  "striking  block"  may  be  an  anvil  or  a  large 
wooden  block  set  in  sand,  and  the  base  of  the  counter-die  must 
rest  steadily  upon  it.  As  there  is  always  a  hollow  in  the  back 
of  a  zinc  die,  a  conical  piece  of  iron,  steel,  or  other  hard  metal, 
should  be  placed  upon  it  to  centralize  the  blow  of  the  hammer. 
To  a  disregard  of  these  precautions  is  due  all  the  difficulty,  so 
often  complained  of,  in  the  tilting  or  rocking  of  plates  and  dies. 

Throughout  the  entire  process  of  swaging  the  plate  must  be 
frequently  annealed.  It  may  be  suddenly  cooled  after  all  except 
the  final  annealing;  when  the  cooling  must  be  very  gradual,  so 
as  to  avoid  warping  or  springing. 

When  block  tin,  lead  or  fusible  metal,  dies  or  counter-dies, 
are  u.'^ed  in  swaging  the  plate,  any  portion  of  these  metals  which 
may  adhere  to  it  should  be  removed  before  annealing,  as  their 
fusion  upon  its  surface  alloys  them  with  the  gold  and  will  render 
it  brittle  and  impair  its  ductility,  or  else  eat  holes  in  the  plate 
at  the  spots  where  the  particles  of  baser  metal  form  an  alloy, 
fusible  at  the  annealing  heat.  The  liability  of  the  tin  or  lead 
to  adhere  to  the  gold  may  be  measurably  prevented  by  oiling 
tiie  plate  before  it  is  struck  up. 

After  fitting  the  plate  to  the  metallic  die,  it  is  applied  to  the 
mouth,  fur  the  purpose  of  ascertaining  if  the  impression  from 
which  the  model  was  procured  is  correct.  It  sometimes  happens 
that  this  is  imperfect;  in  which  case,  a  new  one  will  have  to  be 
taken,  and  the  whole  process  of  procuring  plaster  and  metallic 
models  and  counter-models  again  gone  through  with;  hence  the 
propriety  of  the  precaution  of  trying  it  in  the  mouth  before  the 
clasps  and  teeth  are  attached.  To  be  worn  with  comfort,  and  at 
the  same  time  to  subserve  any  valuable  purpose,  it  is  important 
that  the  plate  should  fit  perfectly  all  the  inequalities  of  the  parts 


I 


FITTING   THE    CLASPS.  665 

to  which  it  is  applied.  When  an  unbroken  series  of  several  teeth 
are  to  be  supplied,  it  seldom  happens  that  much  difficulty  is 
experienced  in  fitting  the  plate,  but  when  the  loss  of  six  or  eight 
teeth,  from  different  parts  of  the  dental  arch,  are  to  be  replaced, 
a  perfect  adaptation  to  the  various  inequalities  of  all  the  parts 
cannot  always  be  so  easily  secured. 

With  regard  to  the  size  of  the  plate,  and  the  special  form  that 
should  be  given  to  it  in  different  cases,  the  reader  will  be  able 
to  form  some  idea  from  the  illustrations  to  be  given  in  a  subse- 
(juent  chapter.  In  full  sets,  the  next  step,  after  the  fitting  of 
the  plate,  is  to  obtain  the  antagon.ism  of  the  jaws,  technically 
termed  the  "articulation."  But  in  partial  cases,  when  it  is 
decided  to  use  clasps,  the  next  process  is 

FITTING  THE  CLASPS. 

The  gold  employed  for  clasps  should  be  about  one-third  or 
one-half  thicker  than  the  plate,  and  when  practicable,  nearly  as 
wide  as  the  crowns  of  the  teeth  are  long,  and  carefully  and 
accurately  fitted.  Some  clasps  are  best  made  of  half  round 
wire  and  narrow;  others  may  be  broader  and  thinner.  Some 
may  fit  the  tooth  close  to  the  gum ;  but  in  other  cases,  the  shape 
of  the  tooth,  absorption  of  the  alveolus,  or  morbid  sensitiveness 
of  the  neck,  forbid  this.  Clasps  must  fit  with  accuracy,  and  be 
adjusted  with  great  precision.  This  is  necessary  to  secure  to  the 
piece  the  greatest  possible  amount  of  stability,  and  to  prevent 
them  from  exercising  an  undue  strain  upon  the  teeth.  These 
are  precautions  which  should  never  be  overlooked ;  for  if  the 
clasps  act  unequally  upon  the  teeth,  or  chafe  against  sensitive 
parts,  inflammation  of  the  alveolo-dental  membrane  may  be  set 
tip,  followed  by  wasting  of  their  sockets,  and  ultimate  loss  of 
the  teeth. 

With  the  plate  in  position  in  the  mouth  a  wax  impression  may 
be  taken,  which,  adhering  to  the  plate,  will  remove  it  on  being 
withdrawn,  and  give  its  correct  relation  to  the  teeth  which  are 
to  be  clasped.  Others  adopt  the  less  accurate  method  of  adjust- 
ing the  plate  to  the  original  plaster  model.  But  as,  for  reasons 
before  given,  it  is  advisable  to  cut  off  the  teeth  from  the  model 


666  FITTING   THE    CLASPS. 

used  in  moulding,  a  second  model  is  necessary,  and  usually  for 
this  purpose  a  second  impression. 

When  accurately  fitted,  they  may  be  at  once  soldered  on  the 
model ;  or  may  be  attached  to  the  plate  by  means  of  a  small  piece 
of  wax,  or  cement  composed  of  one  part  wax  and  two  of  resin, 
softened,  and  applied  to  the  plate  and  to  the  inner  or  palatine 
side  of  each  clasp.  The  plate  and  clasps  thus  united,  are  care- 
fully removed  from  the  plaster  model  and  laid  Avith  the  convex 
side  downward  on  a  piece  of  paper. 

Plaster  is  now  poured  on  the  upper  side  of  the  plate  and 
clasps  to  the  thickness  of  half  an  inch.  After  this  has  set,  the 
piece  may  be  taken  from  the  paper,  placed  on  charcoal,  the  wax 
being  softened  and  removed,  and  prepared  for  soldering. 

This  is  the  simplest  way  of  fitting  the  clasps  to  the  plate  and 
preparing  the  piece  for  soldering;  but  when  the  teeth  in  the 
mouth,  to  which  these  fastenings  are  to  be  applied,  deviate  from 
a  vertical  position,  or  when  the  teeth  are  of  such  shape  that  the 
wax  impression  does  not  copy  them  accurately,  this  method  is 
not  reliable.  The  clasps  must  then  be  fitted  to  the  teeth  in  the 
mouth,  instead  of  on  the  plaster  model,  and  may  then  be  attached 
to  the  plate,  as  just  directed.  In  this  case,  only  one  can  be 
attached  at  a  time,  and  after  this  has  been  soldered,  it  should  be 
opened,  the  piece  placed  back  in  the  mouth,  and  the  other  made 
fast  to  the  plate.  The  greatest  care  too  will  be  necessary  to 
prevent  moving  or  altering  the  position  of  the  clasp  in  taking 
the  piece  from  the  mouth. 

Dr.  Fogle  adopts  a  different  method  for  securing  accurate 
adaptation  of  the  clasps.*  These  are  first  fitted  to  the  plaster 
model,  leaving  the  ends  straight.  A  narrow  strip  of  plate,  about 
five-eighths  of  an  inch  in  length,  is  employed  as  the  temporary 
fastening,  one  end  of  which  is  soldered  to  the  lingual  surface  of 
the  clasp;  the  plate  and  clasp  are  now  both  placed  on  the 
model,  and  the  other  end  fitted  and  soldered  to  the  plate, 
forming  a  sort  of  semicircle  or  bow.  Fig.  208  represents  the 
plate,  clasps,  and  temporary  fastenings  on  the  plaster  model. 
In  Fig.  209  they  are  seen  separate  from  the  model. 

The  clasps  are  now  adjusted  to  the  model;  but  however  accu- 
rately this  is  done,  it  will  be  found,  on  applying  the  plate  to  the 

*  Amer.  Jour,  and  Lib.  Dent.  Sci.,  vol.  10,  p.  35. 


FITTING   THE   CLASPS. 


667 


mouth,  that  they  will  not  fit  the  teeth  there;  but  after  properly 
adjusting  them,  the  temporary  fastenings  will  be  found  sufiicient 


Fig.  208. 


Fig.  209. 


to  hold  the  clasps,  while  the  piece  is  being  removed,  in  the  exact 
position  in  which  they  are  placed.  This  done,  it  may  be  in- 
vested in  plaster,  placed  on  charcoal,  and  the  other  steps  con- 
nected with  the  process  of  permanent  soldering  gone  through 
with. 

In  speaking  of  this  method  of  applying  clasps.  Dr.  Cushman 
says:*  ''  In  very  difficult  cases  of  adjustment,  as  where  the  clasp- 
teeth  stand  leaning,  and  where  you  have  to  fasten  to  the  second 
or  third  molars,  it  will  be  found  still  more  advantageous  to  pur- 
sue this  plan — after  soldering  one  end  of  the  strip  to  the  clasp, 
and  having  bent  the  other  to  touch  the  plate  when  on  the  model, 
put  both  in  their  proper  place  in  the  mouth ;  then  with  a  sharp 
pointed  instrument,  indicate  the  point  where  the  bow  touches 
the  plate,  place  them  on  the  model  again,  adjust  the  end  of  the 
bow  to  the  point  marked,  confine  it  there  and  solder  fast.  Dr. 
Cushman,  who  furnished  the  author  with  the  model  from  which 
the  drawings  in  Figs.  208,  209,  were  made,  says,  further,  that 
he  considers  this  method  of  adjusting  clasps  so  valuable  that  he 
never  ventures  to  set  clasps  permanently  in  the  simplest  case  by 
the  model. 

Dr.  Lester  Noble,  Demonstrator  in  the  Baltimore  College  of 
Dental  Surgery  during  the  session  of  1850-'51,  suggests  another 
method,  which  is  thus  described  by  Prof.  Austen : 

"  Let  the  clasp  bind  upon  the  tooth  only  with  sufficient  firm- 

*  American  Journal  of  Dental  Science,  No.  1,  vol.  10. 


668  FITTING   THE    CLASPS. 

ness  to  keep  it  in  its  proper  place.  Then  mix  a  small  quantity  .|| 
of  plaster  from  a  lot  which,  by  previous  trial,  you  find  requires 
four  or  five  minutes  to  set ;  put  it  upon  a  piece  of  paper  or  sheet 
lead  about  an  inch  square,  and  just  before  it  begins  to  harden, 
introduce  it  into  the  mouth  upon  the  fore-finger,  pressing  it  into 
gentle  contact  with  a  portion  of  the  plate  and  about  one-half  of 
the  clasp.  It  must  be  held  there  for  three  or  four  minutes,  until 
it  is  sufficiently  hard  to  break  with  a  sharp  fracture ;  this  point 
you  can  determine  by  examining  the  plaster  left  in  your  bowl. 
The  plaster  must  then  be  withdrawn.  Sometimes  plate,  clasp 
and  plaster  will  be  brought  away  together;  or  the  plaster  and 
clasp  together,  leaving  the  plate;  or  the  plaster  will  separate, 
leaving  both  clasp  and  plate  in  the  mouth.  Should  the  plaster 
by  any  accident  break,  it  can  readily  be  united  at  the  point  of 
the  fracture,  without  in  the  least  altering  its  shape — one  great 
advantage  over  wax.  If  the  plaster  adheres  to  the  plate  on 
withdrawal  from  the  mouth,  it  must  then  be  carefully  detached, 
the  plate  replaced,  and  the  same  process  repeated  for  the  second 
clasp ;  or  possibly  the  impressions  for  both  clasps  can  be  taken 
at  once. 

"  Several  precautions  are  necessary.  If  the  clasp  bind  too 
tightly  around  the  tooth,  its  ends  will,  when  removed,  spring 
together,  and  thus  it  will  not  exactly  fill  the  original  impression 
made  in  the  plaster.  If  the  part  of  the  clasp  which  you  design 
to  cover  with  plaster  be  so  regular  in  shape  as  to  make  its  ad- 
justment, when  out  of  the  mouth,  uncertain,  mark  it  with  a  file 
or  by  a  small  point  of  solder;  this  will  be  copied  in  the  plaster, 
and  remove  all  doubt  as  to  its  definite  position.  If  the  plaster 
be  extended  over  some  part  of  the  edge  of  the  plate,  it  will,  in 
the  absence  of  any  marked  irregularities  of  surface,  give  a  better 
guide  for  its  readaptation.  Lastly,  if  the  plaster  cover  too  much 
of  the  clasp-tooth,  it  will  be  more  liable  to  break  on  being  with- 
drawn. 

"  Take  now  the  clasps,  place  them  each  in  their  separate  im- 
pressions in  the  pieces  of  plaster,  securing  them  if  necessary  by 
a  small  piece  of  softened  wax.  Place  one  end  of  your  plate  in 
its  corresponding  bed  in  one  of  the  plaster  pieces.  If  proper 
care  has  been  used,  both  clasp  and  plate  will  fit  into  the  plaster 
with  unerring  accuracy,  and  of  course  hold  the  precise  relation 


FITTING   THE    CLASPS.  669 

as  when  in  the  mouth.  While  in  this  position,  cover  the  clasp 
and  the  under  surface  of  the  plate  with  fresh  plaster,  or  plaster 
and  sand ;  when  this  has  hardened,  remove  the  first  plaster,  just 
as  in  other  cases  you  would  remove  the  wax,  preparatory  to 
-oldering." 

The  methods  of  Drs.  Fogle  and  Noble  may  be  thought  too 
tedious  for  cases  where  the  shape  and  position  of  the  teeth  is 
-uch  that  a  wax  impression  will  accurately  copy  them;  but  in 
tlie  majority  of  cases  it  will  be  found  essential  to  accurate  ad- 
justment to  resort  to  one  or  other  of  them. 

The  accurate  adaptation  of  the"  clasp  to  the  surface  of  the 
tooth  is  too  often  neglected.  It  is  commonly  done  with  round 
|)liers,  making  trial  from  time  to  time  upon  the  tooth  of  the 
model.  Professor  Austen  condemns  this  as  an  uncertain  method 
in  any  case,  and  as  utterly  worthless  in  many.  He  says:  "Al- 
ways take  a  separate  plaster  impression  of  the  teeth  to  be  clasped ; 
for  which  purpose  use  a  small  cup  of  wax,  lead  or  tin-foil,  one- 
eighth  inch  larger  than  the  tooth.  Let  the  plaster  get  quite 
hard,  then  slightly  open  the  impression,  withdraw  it  and  close 
up  the  fissure.  Make  from  this  either  a  plaster,  or  a  fusible 
metal  tooth:   if  the  former,  harden  it  with  soluble  glass." 

Extreme  accuracy  of  fit  may  most  easily  be  obtained  when 
the  contour  of  the  tooth  is  irregular,  by  the  following  method: 
Burnish  down  to  the  tooth  a  strip  of  very  thin  platina;  then  on 
the  outside  of  this  strip  lay  pieces  of  gold  (of  the  fineness  suit- 
able for  clasps),  with  borax,  and  flow  them  with  the  blowpipe. 

The  principles  of  soldering,  and  many  of  the  appliances  being 
the  same  for  clasps  as  for  soldering  the  teeth  to  the  plate,  they 
will  be  described  in  the  next  chapter. 


CHAPTER    TENTH. 
PRINCIPLES  AND  APPLIANCES  OF  SOLDERING. 

Soldering  is  the  union  of  two  metallic  surfaces ;  either  by 
slightly  fusing  the  surfaces  themselves  (technically  termed  "sweat- 
ing" or  autogenous  soldering),  as  in  the  union  of  a  plate  of  sil- 
ver to  the  block  of  copper  preparatory  to  rolling  it  into  "Shef- 
field plate;"  or  by  the  fusion  of  an  alloy  which  melts  more 
readily  than  the  metals  to  be  soldered. 

The  conditions  of  successful  soldering,  as  given  by  Professor 
Austen,  are :  "  1.  A  freely  flowing  solder.  2.  Absence  of  oxide 
from  the  surface  over  which  the  solder  is  to  flow.  3.  Sufficient 
beat  in  the  surface  to  attract  and  unite  with  the  solder. 

"  The  first  condition  requires  good  solder.  Of  this  we  have 
elsewhere  spoken.  The  second  calls  for  the  use  of  borax,  the 
specific  action  of  which  as  a  'flux'  is — first,  the  removal  of  ex- 
isting oxide,  by  virtue  of  its  powerful  affinity  for  it ;  se- 
condly, the  prevention  of  further  oxidation  by  the  exclusion 
of  the  oxygen  of  the  air.  The  third  condition  demands  that 
skillful  management  of  the  heat,  which  is  the  principal  difficulty 
with  most  beginners,  and,  indeed,  with  not  a  few  old  practi- 
tioners. 

"  The  borax  should  be  used  in  the  lump,  and  rubbed  with  pure 
(distilled  or  rain)  water  upon  a  coarsely-ground  glass  slab,  until 
a  creamy  paste  is  formed.  Into  this  the  pieces  of  solder  may 
be  placed,  and  also  some  of  it  applied  with  a  small  brush  or 
feather  to  the  surfaces  over  which  the  solder  is  required  to  flow. 
Hard  water  and  the  common  practice  of  rubbing  borax  on  a 
slate  make  it  impure,  and,  to  some  extent,  interfere  with  solder- 
ing. Too  much  borax  is  objectionable,  and  gold  requires  less 
than  silver. 

"In  fulfilling  the  third  condition — the  management  of  the 
heat — the  following  points  demand  attention — (a)  To  raise  the 
heat  very  gradually  until  the  water  of  crystallization  of  the 
borax  is  slowly  driven  off";  for  if  this  is  done  rapidly,  the  borax 


SOLDERING. 


671 


puffs  up  and  throws  off  the  solder ;  also  when  there  are  teeth, 
rapid  heating  at  the  outset  is  apt  to  crack  them,  {b)  To  diffuse 
the  heat,  when  using  the  blow-pipe,  so  that  the  solder  shall  not 
become  melted  before  the  metallic  surfaces  are  hot  enough  to 
unite  with  it;  else  it  will  roll  into  a  ball,  or  flow  with  an  abruptly- 
defined  edge;  whereas  it  should  unite  so  smoothly  with  the  plate, 
that,  except  for  the  difference  in  color,  its  line  of  termination 
cannot  be  detected,  (c)  To  manage  the  fine  point  of  the  blow- 
pipe-flame as  to  be  able  to  direct  the  flow  of  the  solder  to  any 
given  point ;  the  rule  being,  that,  unless  prevented,  solder  will 
flow  toward  the  hottest  point.  There  are  two  kinds  of  flame 
given  by  the  blast  of  the  blow-pipe:  1.  The  broad,  heating  up, 
or  oxidizing  flame  ;  this  is  produced  by  holding  the  tip  a  little 
behind  or  at  the  edge  of  the  flame.  2.  The  pointed,  soldering, 
or  deoxidizing  flame  ;  this  is  produced  by  passing  the  tip  more 
or  less  into  the  flame.  A  very  general  mistake  is,  to  use  too 
strong  a  blast. 

"The  apparatus  required  for  soldering  includes:  a  lamp  to 
give  a  sufiiciently  hot  flame ;  a  blow-pipe  to  give  intensity  and 
direction  to  the  flame;  borax,  brush,  glass,  slate,  solder  and 
solder-tongs;  investing  materials  and  clamps,  to  protect  the 
teeth,  also  to  hold  the  parts  in  relation  to  each  other  until  sol- 
dered; a  receptacle  to  retain  or  give  additional  heat  during  the 
process  of  soldering;  an  acid  (sulphuric)  bath  to  remove  the 
glass  of  borax." 

The  simplest  form  of  lamp  is  shown  in  Fig.  210,  holding  about 
a  pint,  and  having  a  Avick  three-fourths  of  an  inch  or  one  inch 
in  diameter.  As  accidents 
sometimes  occur  from  the  flame 
communicating  with  the  explo- 
sive mixture  of  air  and  alco- 
holic vapor  in  the  body  of  the 
lamp,  it  is  prudent  to  make  a 
safety-lamp  by  connecting  the 
wick-tube  with  the  body  of  the 
lamp  by  a  small  tube,  whicli 
shall  be,  under  all  circum- 
stances, full  of  alcohol.  Fig, 
211  represents  such  a  lamp,  provided  the  wick  is  not  permitted 


Fig.  210. 


G72 


SOLDERING. 


to  run  down  as  low  as  the  horizontal  tube.     The  top  of  the  wick 
tube  should  be  beveled  off  in  a  direction  just  the  reverse  of  that 


Fig.  211. 


Fig.  212. 


ficd  in  several  ways,  and  made  more  useful.  First  by  cutting  it 
within  three  inches  of  the  flame-end,  and  inserting  a  small  hol- 
low ball  or  cylinder  to  receive  the  condensed  moisture,  which, 


shown  in  the  drawing,  so  as  to  permit  the  downward  projection 
of  the  flame.  Fig.  212  is  a  very  ingenious  modification  of  the 
safety-lamp,  made  by  Dr.  B.  W.  Franklin,  so  constructed  as  to 

retain  the  alcohol  uniformly  at  the 
same  level. 

The  fluid  used  in  these  lamps  is 
usually  alcohol.  Ethereal  oil  is 
also  used,  and  gives  a  hotter  flame, 
but  it  is  not  quite  so  safe.  For 
all  purposes  of  soldering  we  re- 
gard alcohol  suflicient,  and  it  is 
much  more  cleanly  than  the  carbon- 
iferous flame  of  aethereal-oil,  sperm- 
oil  or  coal-oil. 

Next  in  the  order  given  upon 
page  671,  is  the  blow-pipe.  The 
simplest  is  a  tapering  tube,  fifteen  to  eighteen  inches  long  and 
curved  at  the  smaller  end  (Fig.  213).  At  this  end  the  bore 
for  the  last  half-inch  should  be  perfectly  cylindrical,  and  about 
as  large  as  a  medium-sized  knitting-needle.     This  may  be  modi- 

FiG.  213. 


SOLDERING. 


673 


in  the  plain  blow-pipe,  often  interrupts  the  blast.  Secondly,  by 
attaching  a  flattened  mouth-piece,  which  it  is  much  less  fatiguing 
to  the  lips  to  grasp.  Thirdly,  by  connecting  the  flame-end  to 
the  mouth-piece  by  from  six  to  twelve  inches  of  flexible  tubing. 
This  will  be  found  to  be  a  very  valuable  modification. 

The  mouth-blow-pipe  requires  for  its  use  a  peculiar  manage- 
ment of  the  muscles  of  the  chest,  cheeks  and  palate,  by  virtue 
of  which  an  uninterrupted  and  regular  current  of  air  is  thrown 
from  the  lungs  through  the  pipe.  The  art  once  learned,  is  never 
forgotten.  But  many  will  not  master  the  first  difiiculty  of  learn- 
ing it,  and  become  the  slaves  to  mechanical  appliances,  which, 
however  useful  for  many  purposes,  can  never  supply  the  place 
of  this  simplest  and  best  of  all  blow-pipes. 

Blow-pipes  working  by  artificial  blast  are  divided  by  Professor 
Austen  into  four  classes:  1.  Alcoholic  or  self-acting  blow-pipes; 
2.  Mechanical  or  bellows  blow-pipes;  3.  Hydrostatic  blow-pipes; 
4.  Oxo-hydrogen  or  aero-hydrogen  blow-pipes.  Of  each  of  these 
we  shall  give  an  example.  To  enumerate  all  the  forms  that  in- 
ventive talent  has  devised  would  fill  too  much  of  our  space. 

Fig.  214. 


The  SELF-ACTING  blow-pipes  derive  the  force  of  their  blast  from 
the  vapor  of  hot  alcohol,  which,  igniting  as  it  passes  through 
the  flame,  adds  to  the  intensity  of  the  heat.  A  somewhat  com- 
plex, but  very  complete,  blow-pipe  of  this  class,  invented  by 
Dr.  Jahial  Parmly,  is  shown  in  Fig.  214. 

The  lamp  (G),  supplied  from  the  reservoir  (D  D),  heats  the 


674 


SOLDERINa. 


Fig.  215. 


alcohol  in  globe  (I),  supplied  from  the  reservoir  (J)  through  the 
pipe  (N).  The  elastic  vapor  escapes  at  the  jet  (P),  giving  in- 
tensity to  the  large  flame  (L),  which  receives  its  supply  of  alco- 
hol from  reservoir  M  J.  Both  upper  and  lower  wick  tubes  have  ' 
movable  cylinders  for  regulating  the  flame,  A  small  charcoal- 
furnace  (R)  may  be  brought  in  range  of  the  flame  for  melting 
purposes. 

Smaller  and  more  portable  lamps  are  made,  of  which  quite 
a  number  of  different  patterns  are  to  be  found  in  the  depots. 

The  principle  and  general 
plan  of  construction  is  very 
clearly  shown  in  Fig.  215, 
designed  by  Dr.  S.  S.  White. 
All  alcoholic  blow-pipes  give 
intensity  of  heat,  but  are 
greatly  inferior  to  the  mouth 
blow -pipe  in  the  control 
which  the  operator  has  over 
the  force  and  direction  of  the 
jet. 

The  different  forms  of  the 
MECHANICAL  blow-pipe  are 
almost  infinite.  The  principle  of  construction  is  either  that  of 
the  bellows  or  the  force-pump,  combined  with  a  reservoir  of  air 
to  give  uniformity  to  the  blast,  which  would  otherwise  issue  in 
jets. 

A  common  house-bellows,  secured  to  the  floor,  will  form  a 
simple  and  good  arrangement.  A  spring  should  separate  the 
handles,  the  upper  one  of  which  forms  the  treadle.  An  india- 
rubber  pipe  should  pass  from  the  nozzle  to  an  air-tight  box,  from 
which  a  second  tube  comes  out  and  is  attached  to  the  blow-pipe. 
If  the  bellows  is  made  double,  like  a  blacksmith's,  the  upper 
half  forms  the  air-ciuimber,  in  place  of  the  air-tight  box. 

In  Fig.  216  is  shown  a  double-cylinder  bellows,  ten  inches  in 
diameter,  moved  by  a  treadle  attached  to  the  rod  {df)  which 
passes  under  the  soldering-table.  In  the  drawing  it  is  combined 
with  an  alcohol  blow-pipe,  as  designed  by  Dr.  W.  H.  Elliot,  of 
Montreal ;  but  it  may  be  used  independently  by  attaching  a 
flexible  tube,  with  brass  point,  to  the  air-pipe  {a  a).      The  fol- 


\ 


SOLDERING. 


675 


lowing  excellent  remarks  by  Dr.  Elliot,  upon  this  combination, 
will  be  found  very  instructive: 

"  The  fact,  that  the   centre  of  the  flame  of  the   self-acting 


Fig.  216. 


blow-pipe  contains  no  oxygen,  is  well  known  to  every  enlight- 
ened dentist,  and  may  be  proven  by  placing  a  rod  of  polished 
metal  in  the  flame  for  a  few  seconds,  in  which  case  it  will  be 
seen  that  the  surface  of  that  portion  of  the  rod  occupying  the 
centre  of  the  flame  does  not  unite  with  oxygen,  however  great 
the  degree  of  heat  may  be;  but  if  a  jet  of  atmospheric  air  be 
thrown  into  the  flame  upon  the  rod,  it  will  oxidize  as  readily  as 
if  heated  by  any  other  means.  This  little  experiment  proves, 
not  only  the  want  of  oxygen  in  the  flame,  but  it  leads  to  the 
very  important  conclusion,  that,  without  oxygen,  the  burning  of 
the  vapor  mnst  be  gradual  and  imperfect.  In  consideration  of 
this  fact,  the  writer  was  led  to  make  the  experiment  of  produc- 
ing a  more  perfect  combustion  by  throwing  into  the  flame  one  of 
its  supporters.  This  may  be  done  in  several  ways,  but  the  sim- 
plest and  most  convenient  is  atmospheric  air,  thrown  in  by  means 
of  a  bellows.  The  air  from  the  lungs  will  not  do  as  well,  inas- 
much as  it  not  only  contains  less  oxygen,  but  also  contains  a 
large  portion  of  carbonic  acid,  which  just  so  far  renders  it  unfit 
for  the  support  of  combustion. 

"  The  air-pipe  should  pass   along  by  the  vapor-pipe,  and  dis- 


676  SOLDERING. 

charge  about  an  inch  and  a  half  beyond  it  in  the  very  centre  of 
the  flame,  and  in  precisely  the  same  direction.  The  calibre  of 
the  air-pipe  at  its  apex  must  be  equal  to  that  of  the  vapor-pipe. 
It  must  be  made  as  small  as  possible  without  being  enlarged  at 
the  end,  as  any  enlargement  there  would  derange  the  vapor- 
flame.  It  must  also  be  constructed  of  platina,  as  that  is  the 
only  metal  that  will  resist,  for  any  length  of  time,  the  heat  of 
the  burning  vapor. 

"The  air-pipe  appears  to  throw  out  a  pale-blue  flame,  about 
two  inches  in  length,  small  and  pointed.  At  the  very  point  of 
this  flame,  the  oxygen  being  all  consumed,  the  greatest  amount 
of  heat  is  produced,  and  the  fusion  of  the  solder  takes  place 
without  oxidation ;  but  within  the  blue  flame,  where  oxygen  pre- 
ponderates, oxidation  of  the  solder  goes  on  rapidly.  The  extra 
heat  gained  by  the  introduction  of  the  air-pipe  is  nearly  all 
concentrated  at  the  apex  of  the  blue  flame,  which  may  be  brought 
to  bear  upon  the  point,  to  be  soldered,  while  the  vapor-flame 
keeps  up  the  temperature  of  the  whole  work."' 

Dr.  R.  Somerby,  of  Louisville,  has  constructed  a  combined 
furnace  and  blow-pipe,  which  will  be  found  very  convenient  and 
useful  in  the  laboratory  (Fig.  217).  The  double  bellows  (o), 
worked  by  the  treadle  (r),  sends  its  blast — which  may  be  in- 
creased by  the  weight  (p) — up  the  pipe  (n),  either  to  the  furnace 
(«■),  or  through  the  blow-pipe  point  (d)  into  the  flame  of  the  lamp 
(6),  which  rests  on  a  sliding  ring  (/),  attached  to  the  movable 
stand  {h).  The  frame  is  of  cast-iron,  the  pipes  of  brass,  the 
lamp  of  copper,  and  the  entire  apparatus  admirably  made  and 
of  the  best  material.  When  the  furnace  is  used,  a  hood,  resting 
against  the  flange  (a),  carries  oS"  the  smoke,  and  a  pan  {j)  re- 
ceives the  ashes.  If  desirable,  the  fire  may  be  started  by  the 
blast,  and  then  continued  by  simple  draft  through  the  door  (k) ; 
this  can  be  made  of  any  required  intensity  by  a  pipe  set  di- 
rectly over  the  top  of  the  furnace.  The  process  of  soldering  is 
rendered  more  easy  by  this  blow-pipe  than  by  the  usual  method, 
and  is,  therefore,  to  those  of  the  profession  who  are  stationary, 
and  occupy  themselves  much  in  mechanical  dentistry,  invaluable. 
The  furnace  attached  to  it  answers  all  the  purposes  of  melting 
gold,  solder  and  metallic  casts. 

"  The  THIRD  class  of  blow-pipes,"  says  Prof.  Austen,  "is  some- 


SOLDERING. 


677 


times  combined  -with  the  second  to  regulate  the  blast,  or  with  the 
first  to  intensify  the  blast.     In  its  uncombined  form  it  consists 


Fig.  217. 


essentially  of  a  blow-pipe  point  attached  by  a  flexible  tube  to  an 
air-chamber,  from  which  the  air  is  forced  by  the  steady  pressure 
of  water.  When  once  set  in  operation,  it  is  self-acting,  and  in 
this  respect  has  great  advantage  over  the  second  class.  This, 
with  the  perfect  regularity  of  the  blast,  makes  a  properly  con- 


f 


678 


SOLDERING. 


structed  hydrostatic  blow-pipe  much  the  best  of  all  substitutes 
for  the  lungs  and  mouth  blow-pipes. 

"The  following  description  will  explain  a  simple  and  inex- 
pensive apparatus  contrived  by  me  for  those  laboratories  where 
no  pressure  can  be  had,  as  in  cities,  from  public  water-works. 
Place  in  convenient  position  a  strong  ten-gallon  water-tight  oak 
cask,  two  feet  from  the  floor.  Over  this,  and  two  feet  above  it, 
place  a  second  of  the  same  size,  with  a  movable  cover,  so  that 
water  may  conveniently  be  poured  into  it.  Connect  the  casks 
by  a  tube  running  nearly  to  the  bottom  of  the  lower  cask,  and 
having  a  stop-cock  (1)  between  the  casks.  Into  the  top  of  the 
lower  cask  insert  a  stop-cock  (2),  to  which  attach  the  blow-pipe 
tube,  and  into  the  bottom  a  larger  stop-cock  (3)  for  drawing  off 
the  water.  It  is  prepared  for  operation  thus:  close  all  the  stop- 
cocks, and  fill  the  upper  cask  to  within  an  inch  of  the  top  (if 
too  full,  it  might  chance  to  overflow  the  lower  cask  and  force 
water  out  of  the  blow-pipe  upon  the  flame  and  work);  then  open 
stop-cocks  2  and  3,  and  the  jet  issues  with  a  force  proportioned 
to  the  height  of  the  water.  If  too  strong,  it  may  be  regulated 
by  pressure  upon  the  elastic  tube,  or  by  partly  closing  the  stop- 
cock. Ten  gallons  of  air  will  suffice  for  any  ordinary  case  of 
Fig.  218.  soldering;  but  the  process  is  easily  re- 

newed by  closing  stop  1  and  drawing 
off  the  water  by  stop  3  from  the  lower 
cask,  and  emptying  into  the  upper. 
This  can  be  more  rapidly  done  if  a 
fourth  stop-cock  is  put  in  the  top  of  the 
lower  cask  to  admit  air  freely  while 
drawing  off  the  water. 

"Another  but  more  expensive  form 
is  shown  in  Fig.  218,  made  of  copper 
or  boiler  iron,  and  connected  by  lead 
pipes  with  the  public  water-works,  in 
towns  and  cities  thus  supplied.  The 
drawing,  taken  in  connection  with  the 
previous  description,  makes  any  expla- 
nation unnecessary." 
There  is  still  another  class  of  blow-pipes,  analogous  in  their 
operation  to  the  oxo-hydrogen  blow-pipe.     The  point  is  double, 


SOLDERING. 


679 


Fig.  219. 


consisting  of  a  tube,  through  which  comes  the  supporter  of 
combustion  (oxygen  or  common  air),  surrounded  by  a  cylinder, 
through  which  comes  the  combustible  (alcoholic  vapor,  illuminat- 
ing gas  or  hydrogen).  In  Count  Richmont's  aero-hydrogen  blow- 
pipe, the  hydrogen  is  generated  in  a  vessel  by  the  action  of  dilute 
sulphuric  acid  upon  zinc,  and  the  air  forced  through  the  centre 
tube  either  with  a  bellows  or  from  the  lungs.  The  heat  is  less 
intense  than  that  of  the  oxo-hydrogen  blow-pipe,  but  is  too  great 
for  most  laboratory  purposes.  In  the  various  forms  of  "gas 
l)low-pipes"  the  principle  is  similar  and  the  heat  very  great.  It 
is  a  very  convenient  instrument. 
Fig.  219  reprepresents  Macomber's 
gas  blow-pipe.  The  direction  of 
the  point  (1)  is  regulated  by  the 
joint  (3),  and  the  supply  of  gas 
controlled  by  the  stop-cock  (2).  The 
air  is  supplied  from  the  lungs 
through  the  flexible  tube. 

Parts  to  be  soldered  must  be  held  wj  W\^^^  \, 

together  in  their  exact  relative  po- 
sition. This  can  sometimes  be  done 
by  simply  laying  them  together ; 
but  usually  they  must  be  held  in 
place,  either  by  iron-wire  bound  round  them,  or  by  small  clamps 
of  iron-wire,  or  by  rivets,  or  else  by  some  investing  material, 
which,  in  dentistry,  is  always  plaster  mixed  with  some  substances 
that  will  counteract  its  tendency  to  shrink  and  crack  under  sol- 
dering heat.  This  substance  may  be  coal-ashes,  soap-stone  dust, 
feld-spar,  clean  sand  or  asbestos.  The  two  latter  are  the  best, 
and  may  be  mixed  in  proportions  varying  from  two  to  six  parts 
sand  or  asbestos  to  four  of  plaster.  As  a  rule,  the  less  plaster, 
the  less  the  shrinkage ;  but  too  small  a  quantity  makes  the  invest- 
ment rotten. 

A  common  mistake  is,  to  use  too  large  a  quantity  of  investing 
material.  This  almost  invariably  results  in  the  warping  of  the 
plate;  for,  as  all  investments  have  some  degree  of  permanent 
contraction,  and  all  metal  must  expand,  if  the  latter  is  bound 
by  a  rigid,  unyielding  mass,  it  will  inevitably  warp.  Hence,  as 
a  rule,  use  no  more  investing  material  than  is  necessary  to  keep 


680 


SOLDERING. 


the  parts  to  be  soldered  in  their  position,  and  to  protect  the 
porcehiin  surfaces  from  direct  contact  with  the  flame.  This 
subject  will  be  further  considered  when  speaking  of  the  solder- 
ing of  teeth  to  the  plate. 

In  selecting  a  suitable  receptacle  for  the  work  to  be  soldered, 
it  is  important  to  retain  the  heat,  especially  when  using  the 
mouth  blow-pipe.  A  funnel-shaped  mat  made  with  scraps  of 
woven  iron-wire,  or  a  large  lump  of  pumice-stone,  or  one  of 
close-drained  charcoal  with  the  outside  coated  over  with  a  thin 
layer  of  plaster,  form  very  simple  and  convenient  receptacles 
for  smaller  pieces  of  work.  For  larger  work,  or  for  very  high 
temperatures,  it  is  important  to  receive  additional  heat  from 
ignited  charcoal,  for  which  purpose  the  soldering-pan  (Fig.  220) 
is  a  very  admirable  contrivance.  The  movable  lid  remains 
during  the  heating  up  and  the  cooling  off,  but  is,  of  course,  re- 
moved during  the  act  of  soldering. 


1 


After  soldering,  the  work  should  cool  gradually,  unless  it  is 
to  be  re-swaged.  If  there  is  any  porcelain,  the  cooling  must  be 
very  gradual.  When  cold,  it  may  be  placed  in  dilute  sulphuric 
acid  and  slowly  raised  to  the  boiling  point,  kept  there  for  a  few 
moments,  then  slowly  cooled.  This  dissolves  the  glass  of  borax, 
which  is  very  hard,  and  will  take  the  edge  off  from  files  and 
scrapers. 


SOLDERING.  681 

The  application  of  these  rules  and  apparatus  to  the  soldering 
of  clasps  is  very  simple.  The  surfaces  must  be  free  from  plaster 
or  oxide,  and  the  points  to  be  united  must  not  be  too  widely 
-^Lparated.  The  clasp  should  be  firmly  united,  but  the  line  of 
union  must  not  be  too  wide,  else  the  proper  spring  or  play  of  the 
ends  of  the  clasp  will  be  lost.  Too  much  solder  or  too  much 
borax  makes  slovenly  work.  A  perfectly  soldered  joint  never 
needs  the  file  or  scraper  to  give  it  a  finish. 


44 


CHAPTER    ELEVENTH. 
ANTAGONIZING  OR  ARTICULATING  MODELS. 

If  the  antagonizing  model  is  required  for  only  a  partial  upper 
denture — there  being  natural  teeth  in  the  lower  jaw  that  antagonize 
with  those  which  remain  in  the  upper — it  may  be  obtained  in  the 
following  manner. 

After  having  attached  the  clasps  to  the  plate,  it  should  be 
placed  in  the  mouth,  a  rim  of  softened  bees-wax  being  attached 
to  it  at  the  points  where  teeth  are  required ;  the  patient  is  then 
requested  to  close  the  mouth  naturally^  imbedding  the  teeth  of 
the  lower  jaw  in  the  wax.  While  the  mouth  is  thus  closed,  the 
wax  on  the  outside  of  the  teeth  and  alveolar  ridge  is  pressed 
closely  against  them.  This  done,  the  plate  and  wax  impression 
are  carefully  removed  and  placed  on  a  piece  of  wet  paper,  with 
the  wax  downward.  The  upper  side  of  the  plate  is  then  oiled, 
and  covered  with  thin  plaster.  As  the  plaster  stiffens,  it  may 
be  applied  until  it  is  raised  half  an  inch  above  the  plate,  and 
extended  back  of  it  on  the  paper  an  inch  and  a  half  or  two 
inches.  As  soon  as  the  plaster  has  set,  it  may  be  neatly  trimmed 
around  the  edges,  and  on  the  surface  next  the  paper  or  table, 
beiiind  the  plate  and  wax,  a  deep  transverse  or  T  shaped  groove 
should  be  cut,  or  several  conical  depressions,  three-eighths  of  an  inch 
deep,  to>^erve  as  moulds  for  the  formation  of  corresponding  ridges 
or  protuberances  on  the  half-model  with  which  this  is  to  antagonize. 

This  grooved  surface  must  be  coated  with  oil,  or  soap-water, 
or  varnish,  or  a  layer  of  thin  tin-foil  or  thin  paper.  Then  partly 
fill  tlie  space  enclosed  by  the  ridge  of  wax,  with  clay,  putty  or 
wet  paper,  and  pour  on  plaster  to  form  the  other  half-model. 
Ill  running  plaster  into  the  wax  impressions  of  the  teeth,  be 
very  careful  to  avoid  air  bubbles  and  flaws,  and  do  not  oil  the 
wax.  After  the  plaster  has  set,  it  may  be  trimmed  as  before 
directed.  When  it  has  become  sufficiently  hardened,  the  two 
pieces  may  be  separated  after  softening  the  wax  in  warm  water. 


ANTAGONIZING    OR    ARTICULATING    MODELS.  683 

and  the  wax  and  plate  carefully  removed.  The  model  is  now- 
varnished,  and  when  put  together  will  present  the  appearance 
exhibited  in  Fig.  221. 

Fig.  221. 


By  this  simple  contrivance,  an  exact  representation  of  the 
manner  in  which  the  jaws  meet,  is  obtained,  and  the  most  simple, 
accurate  and  convenient  antagonizing  model  procured  that  can 
possibly  be  made;  provided  w^ith  this,  the  dentist  is  prepared  to 
select,  arrange  and  antao-onize  the  teeth.  But  when  several  natu- 
ral  molars  and  froit  teeth  antagonize  with  those  below.  Prof. 
Austen's  method  may  be  adopted:  which  is  to  take  a  wax  im- 
pression of  the  lower  teeth.  The  model  from  this  will  articulate 
with  the  teeth  of  the  upper  model  just  as  the  natural  teeth  do. 

When  the  antagonizing  model  is  designed  for  a  complete  upper 
denture,  a  piece  of  wood,  equal  in  width  to  the  length  required 
for  the  artificial  teeth  may  be  passed  through  the  wax,  after  it 
has  been  arranged  to  the  plate,  at  a  point  corresponding  with, 
and  in  the  direction  of,  the  median  line.  The  plate  may  then 
be  placed  in  the  mouth,  and  the  patient  directed  to  close  the 
jaw  naturally,  until  the  teeth  of  the  lower  jaw  come  in  contact  with 
the  wood.  Tiien  press  the  wax  against  the  outside  of  the  lower 
teeth  and  remove  the  plate  with  the  adhering  wax  impression 
of  the  lower  teeth.  This  done,  the  two  halves  of  the  articu- 
lating model  maybe  made  in  the  manner  bef(»re  directed.  When 
completed,  it  will  present  the  appearance  represented  in  Fig. 
222. 

An  antagonizing  model  may  also  be  made  by  adjusting  a  rim 
of  wax  to  the  plate  corresponding  in  width  to  the  length  pro- 


684  ANTAGONIZING    OR    ARTICULATING    MODELS. 

posed  for  the  artificial  teeth,  and  trimming  it  until  all  the  teeth 
in  the  lower  jaw  touch  it  at  the  same  instant.  This  done,  the 
plaster  is  applied  as  before  directed. 

Fig.   222. 


But  a  better  plan  than  either  of  these  is  to  adjust  a  rim  of 
gutta-percha,  wtich  shall  represent  the  required  length  and  ex- 
ternal fullness  of  the  teeth.  When  this  is  satisfactorily  adjusted, 
a  small  rim  of  soft  wax  is  placed  on  the  gutta-percha,  and  the 
mouth  closed  as  naturally  as  possible  until  the  teeth  touch  the 
latter.  The  gutta-percha  can  be  readily  trimmed  with  a  sharp 
knife,  and  gives  opportunity  to  ascertain,  by  the  effect  on  the 
expression  of  the  lips,  &c.,  exactly  what  length  and  fullness  of 
tooth  suits  the  particular  case. 

There  is  a  tendency  on  the  part  of  the  patient  to  close  the 
mouth  to  one  side  and  too  far  forward ;  it  is  impossible  to  close 
it  behind  the  natural  articulation.  The  simplest  method  for 
regulating  this  is  to  keep  the  body  erect  and  throw  the  head  back- 
ward, so  as  to  make  as  tense  as  possible  the  throat  muscles  which 
thus  act  as  a  bridle,  and  almost  compel  a  correct  closure  of  the  mouth. 

In  making  an  antagonizing  model  for  a  complete  denture,  or 
double  set  of  artificial  teeth,  the  following  is  the  method  very 
often  adopted.  After  having  fitted  accurately  both  plates,  a  rim  of 
soft  bees-wax  is  placed  between  their  convex  surfaces,  about  an 
inch  and  a  quarter  in  width.  A  piece  of  soft  wood,  exactly  cor- 
responding in  width  to  the  length  it  is  designed  that  the  upper  and 
lower  central  incisors  together  should  have,  is  passed  through  the 
wax  between  the  plates,  at  the  median  line.  The  whole  i.s  now 
placed  in  the  mouth  of  the  patient,  and  each  plate  accurately 
adjusted  to  the  alveolar  border.     The  patient  is  then  directed 


*^ 


ANTAGONIZING    OR    ARTICULATING    MODELS. 


685 


to  close  the  mouth  naturally  until  the  plates  are  brought  in 
contact  with  the  edges  of  the  interposed  piece  of  wood.  This 
done,  the  plate,  wax,  and  wood  are  removed  from  the  mouth 
together,  and  a  plaster  model  (Fig.  223)  obtained  in  the  manner 
before  described. 

Fig    223. 


But  a  far  better  method  of  making  an  antagonizing  model 
consists  in  placing  a  rim  of  wax  or  gutta-percha  on  each  plate 
giving  the  length,  outline,  and  fullness  respectively  designed  for 
the  teeth  of  each  jaw.  The  two  plates  are  put  in  the  mouth, 
and  the  jaws  are  carefully  closed;  if  the  rims  of  wax  touch 
at  any  one  point  sooner  than  another,  the  plates  are  removed, 
and  the  wax  trimmed  ;  this  operation  is  repeated  until  the  two 
rims  of  wax  meet  all  the  way  round,  at  the  same  instant,  and 
give  the  proper  contour  to  the  clieeks  and  lips.  The  median 
line  is  then  marked,  and  the  final  closure  of  the  mouth  made 
with  the  utmost  care,  so  that  there  shall  be  no  lateral  or  forward 
deviation.  The  exact  position  being  secured,  the  lower  jaw  is 
to  be  held  with  the  left  hand,  whilst,  with  the  right,  some  eight 
or  twelve  deep  indentations  are  made  with  a  wax-knife,  across 
the  line  of  contact  between  the  two  rims.  The  pieces  may  be 
removed  separately  from  the  mouth,  and  can  then,  by  the  aid 
of  these  marks,  be  accurately  readjusted.  The  two  halves  of 
the  articulating  model  can  then  be  made  as  previously  directed. 

To  save  plaster,  and  also,  to  permit  modification  of  the  ar- 
ticulation where  inaccuracy  is  suspected,  quite  a  number  of 
frames  have  been  devised — technically  termed  articulators.    One 


686 


ANTAGONIZING    OR    ARTICULATING    MODELS. 


of  the  first  ever  contrived  for  this  purpose,  was  by  Dr.  T.  W. 
Evans,  of  Paris.  It  is  made  of  heavy  brass  wire,  and  presents 
when  the  plaster  models   are   attaclied,  the   appearance  seen  in 

FiQ.   224. 


Fig.  225. 


Fig.  224.     The  part  embedded  in  each  model,  is  a  semi-circular 

continujition  of  the  wire. 

The  articulator  devised  by  Dr.  W.  H.  Smith,  Fig.  225,  will 

be  found  to  be  one  of  the 
best  in  use.  But  when 
plaster  is  abundant  there 
is  no  articulator  better  than 
the  plaster  one.  It  ad- 
mits, however,  of  only  one 
modification  in  case  of 
an  inaccurate  antagonism, 
namely,  widening.  A  care- 
ful manipulator  never  has 
occasion  to  alter  his  ar- 
ticulation. If  modern  im- 
proved articulators  gave 
less  facility  for  doing  so, 
operators  would,  perhaps, 

be  a  little  more   careful,   in    this  very   important   step   in  the 

construction  of  a  piece  of  dental  mechanism. 


CHAPTER     TWELFTH. 

ADJUSTiMENT  OF   PORCELAIN  TEETH   TO  THE   PLATE- 
FINISHING   PROCESS. 

Where  a  vacancy  requiring  only  one  or  several  teeth,  is  to 
be  filled,  it  is  highly  important  that  the  artificial  teeth  correspond 
in  shade  and  color  with  the  natural  organs;  for  in  proportion  as 
they  are  whiter  or  darker,  will  the  contrast  be  striking,  and  their 
artificial  character  apparent.  Of  the  two  faults  it  is  better  that 
they  should  be  a  little  darker  than  any  whiter.  Their  outer  con- 
figuration should  resemble,  too,  the  shape  of  those  which  have 
been  lost,  so  far  as  it  is  possible  to  ascertain  this.  Minute  accuracy 
as  to  shades  of  color,  involves  the  necessity  of  a  large  assort- 
ment, unless  one  is  located  near  a  depot  or  agency.  But  the 
facilities  of  mail  and  express  companies  will  lessen  this  necessity, 
provided  there  is  time  to  send  for  the  tooth  or  teeth  required.  It 
is  desirable,  in  view  of  this  method  of  matching  shades  of  color, 
to  keep  all  refuse  or  broken  teeth,  as  samples  in  sending  orders. 

The  manufacturers  supply  three  kinds  of  plate  teeth — plain, 
gum  and  sections.  The  latter  have  the  advantage  of  showing 
few  joints;  but  are  less  easily  repaired,  and  are  not  applicable  to 
so  wide  a  range  of  cases.  Gum  teeth  are  applicable  only  where 
there  has  been  sufiicient  absorption  to  permit  the  extra-fullness 
of  the  artificial  gum.  Many  mouths  are  deformed  by  a  foolish 
craving  on  the  part  of  the  patient  for  "gums,"  which  the  den- 
tist should  not  be  so  foolish  as  to  yield  to,  when  plain  teeth  will 
make  a  far  more  natural  piece.  In  point  of  strength,  durability 
and  facility  of  repair,  plain  teeth  are  superior  to  the  others:  they 
are  also  more  readily  adapted  to  the  plate. 

When  selected,  they  should  be  arranged  on  the  plate,  and  re- 
tained in  place  by  a  piece  of  wax  placed  on  it  behind  them.  If 
they  do  not  fit  closely  to  the  plate  or  gums,  they  must  be  ground 
on  emery  or  corundum  wheels,  until  accurately  fitted,  and  so 
arranged  as  to  meet  the  teeth  with  which  they  are  intended  to 
antagonize,  at  the  same  instant  around  the  entire  arch  in  full 
cases ;  in  partial  cases  the  natural  teeth  should  touch  their  an- 
tagonists more   decidedly  than  the  artificial   ones.     A  correct 


688 


ADJUSTMENT  OF  PORCELAIN  TEETH. 


antaf^onizing  model  will  enable  the  dentist  to  do  this  with  the 
most  perfect  accuracy. 

In  arran"in<f  an  entire  set  for  the  upper,  or  for  both  jaws,  the 
molars  are  to  be  so  adjusted  that  the  inner  or  palatine  tubercles 
of  the  upper  strike  the  depressions  in  the  lower,  Before  the  outer 
tubercles  come  together.  This  precaution  is  necessary,  in  an- 
taf^onizing  single  as  well  as  block  teeth.  If  the  outer  tubercles 
strike  first,  the  pressure  there  will  spring  and  loosen  the  plate. 
For  the  same  reason  upper  molars  and  bicuspids  should  not  be 
set,  if  it  is  possible  to  avoid  it,  so  that  the  force  of  mastication 
falls  outside  of  the  ridge.  A  small  space,  too,  should  be  left  be- 
tween the  last  tooth  of  the  upper  and  of  the  lower  jaw,  provided 
the  crown  of  the  lower  molar,  as  sometimes  happens,  looks  for- 
ward, its  posterior  edge  being  a  little  higher  than  the  anterior. 

It  is  often  necessary  to  cut  away  a  considerable  portion  of  a 
tooth  in  order  to  make  it  fit  accurately  to  the  plate.  This  will 
make  the  process  of  grinding  very  tedious  unless  tlie  operator 
has  a  number  of  sharp-cutting  corundum  wheels,  varying  from 
half  an  inch  to  three  or  four  inches  in  diameter. 

These  may  be  attached  to  one  of  the  hand  lathes  on  page 
615,  or  to  one  of  the  foot  lathes,  of  which  the  depots  now  furnish 

Fig.  2-26.  Fig.  227. 


some  e.xcellent   varieties.      Fig.   226   represents   an   admirable 
lathe  for  dental  purposes.     While  in  Fig.  227,  we  have  a  larger, 


ADJUSTMENT    OF    PORCELAIN    TEETH. 


689 


stronger,  and  more  powerful  lathe,  capable  of  very  rapid 
motion,  also  adapted  to  the  making  of  small  instruments, 
handles,  &c. 

Those  who  have  laboratory  and  office  in  one  room,  may  wish 
to  unite  the  ornamental  and  the  useful.     Figs.   228,  229,  repre- 


FiG.  228. 


Fig.  229. 


sent  a  piece  of  cabinet  furniture  combining  lathe,  work  table,  and 
drawers  for  implements,  materials,  &c. 

Wheels  may  either  be  set  at  intervals  on  a  long  spindle,  (Fig. 
226,)  or  screwed  singly  on  the  end  of  the  mandril.  (Fig.  227.) 
In  the  latter  case  they  should  be  fixed  with  a  screw  chuck  in  the 
centre,  so  as  to  be  quickly  changed  from  coarse  to  fine  or  from 
large  to  small.  In  grinding,  the  wheel  should  revolve  toward 
the  operator,  and  be  kept  constantly  wet  with  a  sponge  held  either 
in  a  sponge-holder,  or  between  the  ring  finger  and  little  finger 
of  the  left  hand. 

The  thumb  and  forefinger  of  each  hand  must  be  free  to  hold 
the  tooth,  the  right  wrist  being  steadily  supported  on  the  hand 
rest.  Two  faults  are  very  common  in  grinding :  one  is  revolving  the 
wheel  too  rapidly,  the  other,  bearing  the  tooth  too  heavily 
against  the  wheel.  The  first  hinders  rather  than  helps  grind- 
ing ;  the  second  is  very  apt  to  throw  the  tooth  from  the  fingers, 


690 


ADJUSTMENT  OF  PORCELAIN  TEETH. 


and  destroys  the  delicacy  of  touch  necessary  for  accurate 
grinding. 

In  grinding  blocks  and  gum  teeth,  and  often  in  plain  teeth, 
very  small  wheels  are  required  to  make  them  fit  the  curves  of  the 
plate.  Thin  edges  of  gum  teeth  and  blocks  must  be  ground  with 
very  fine  grained  wheels ;  whilst  in  jointing  them  a  three  inch 
wheel  should  be  used,  perfectly  flat  on  its  outer  side,  and  running 
very  true. 

The  teeth  being  thus  arranged  and  adjusted,  a  gold  plate,  or 
backing  large  enough  to  cover  the  entire  width  and  from  eight 
to  nine  tenths  of  the  height  of  the  posterior  surface  of  each,  is 
fitted  to  them  in  the  following  manner — Each  tooth  has  securely 
fixed  in  the  back  part  of  it  two  phitina  rivets,  for  the  purpose  of 
connecting  it  to  the  backing.  Each  backing,  therefore,  should 
have  two  holes  punched  through  it,  by  means  of  a  pair  of  dentist's 
punch  forceps,  like  those  represented  in  Fig.  230,  large  enough 

Fig.   230. 


to  admit  the  rivets  of  the  teeth.  After  having  punched  one  hole, 
a  rivet  is  inserted ;  then,  by  moving  the  strip  of  gold  plate  two 
or  three  times  to  the  right  and  left,  a  mark  will  be  left  upon  it, 
indicating  the  distance  the  rivets  are  apart.  But  previously  to 
this  the  rivets  should  be  made  parallel,  (being  very  careful  not 


ADJUSTMENT  OF  PORCELAIN  TEETH. 


691 


to  strain  them  in  the  tooth,)  and  the  ends  filed  off"  level.  Other- 
wise the  pins  will  not  go  into  the  holes  punched,  and  there  will 
be  an  uncertainty  as  to  which  side  of  the  pin  the  mark  on  the 
plate  corresponds. 

Dr.  Samuel  Mallet  has  very  ingeniously  invented  a  punch  which 
will  save  much  trouble  in  finding  the  proper  position  of  the  second 
hole.    (Fig.  231.)    After  straightening  the  pins,  one  is  placed  in 

Fig.  231. 


the  hole  ^,  at  the  head  of  the  punch,  the  other  pin  pressing  out 
the  movable  punch  e,  (which  works  by  the  spring  g,)  until  it 
slips  into  the  slot  h :  the  two  punches  /,  e,  then  make  the  holes 
at  the  exact  distances  apart  to  receive  the  pins. 

The  holes  should  be  slightly  countersunk  on  both  sides,  and 
after  placing  the  backing  on  the  tooth,  it  is  made  fast  by  split- 
ting with  a  strong  knife  or  a  wedge-shaped  excavator,  the  ends 
of  the  platina  rivets,  or  pinching  them  together  with  pliers.  If 
the  ends  of  the  platina  rivets  are  hammered  so  as  completely  to 
fill  the  holes  in  the  backings,  it  will  prevent  the  solder  from 
flowing  in  and  uniting  the  two  as  firmly  as  it  should  do.  The 
backings  may  be  slightly  hollowed  before  they  are  put  on.  By 
doing  this  they  will  fit  up  closely  to  every  part  of  the  back  of 
the  tooth 

After  the  backings  have  been  made  fast  to  the  teeth,  they  are 
to  be  accurately  fitted  to  the  plaie,  standing  off"  from  the  plate 
enough  for  a  very  thin  piece  of  watch-spring  to  be  pas-ed  under. 
This  makes  it  certain  that  the  tooth  is  not  raised  by  the  backing 
from  its  place  in  the  investment.  A  much  wider  space  makes 
the  flow  of  solder  uncertain  ;  and  the  practice  of  placing  scraps 
of  gold  under  badly  fitted  backings  is  a  very  slovenly  one. 

Some  dentists  back  the  teeth  as  they  grind  and  fit  them,  and 


692  ADJUSTMENT  OF  PORCELAIN  TEETH. 

before  investing.  Others  invest  with  the  soldering  mixture,  and 
back  without  taking  them  from  the  investment.  Others,  again, 
partially  invest  with  the  soldering  mixture,  remove  and  back  the 
teeth  ;  then  replace  and  add  more  plaster  and  sand  (or  asbestos) 
over  the  edges  of  the  teeth.  Professor  Austen's  method  is  thus 
described — "  Fasten  each  tooth  or  block,  as  it  is  ground,  to  the 
plate  with  wax,  placing  tissue  paper  between  the  lateral  joints 
of  gum  or  block  teeth,  to  prevent  actual  contact  (which  some- 
times causes  splintering  of  the  gum  upon  the  contraction  of  the 
plate  after  soldering).  The  grinding  and  articulating  done,  place 
the  half-model  of  the  articulator,  back  downward,  with  plate 
and  teeth  upon  it,  upon  the  plaster  table.  Around  the  outside 
of  the  teeth,  plate  and  articulator  (slightly  oiled,  or  soaped),  run 
a  band  of  pure  plaster  from  one  fourth  to  one  half  an  inch  thick. 
When  hard,  the  wax  is  to  be  removed  from  the  teeth,  and  each 
tooth  or  block  taken  out  separately  and  backed. 

"  The  diflferent  modes  of  backing  I  shall  not  here  describe  fur- 
ther than  to  refer  to  the  two  classes :  1,  those  temporarily 
fastened  to  the  teeth  and  soldered  to  teeth  and  plate  at  the  same 
time ;  2,  those  soldered  to  the  teeth  and  finished  up  before  being 
soldered  to  the  plate. 

"  Sometimes  the  shape  of  a  gum  or  block  tooth  may  require  the 
removal  of  the  plaster  rim,  which  can  be  detached  either  in  one, 
two  or  three  pieces,  and  readily  replaced  after  the  backing  is 
completed,  for  the  final  adjustment  of  the  teeth.  The  teeth  are 
next  to  be  fastened  to  the  plate  with  a  small  quantity  of  cement 
(resin,  mixed  with  wax,  or  still  better,  with  gutta  percha  and 
plaster),  and  a  small  roll  of  softened  wax  (not  melted  or  made 
adhesive)  placed  over  the  entire  surface  to  be  soldered.  The 
plaster  rim  is  then  very  carefully  removed,  and  the  piece  sur- 
rounded with  the  soldering  investment,  which  must  be  no  thicker 
than  is  sufficient  to  protect  the  teeth  and  hold  them  in  place. 
The  wax  and  cement  can  be  very  quickly  removed,  leaving  the 
surfaces  perfectly  clean  and  ready  for  the  borax  and  solder.  The 
investment  should  not  cover  the  lingual  surface  of  the  plate,  nor 
should  it  be  thick  on  the  palatine  surface  ;  on  which  side  it  would 
be  well  also  to  cut  along  the  median  line  nearly  or  quite  through 
the  investment.  The  object  of  this  is  to  give  play  to  the  lateral 
expansion  of  the  plate;  the  antero-posterior  expansion  being 


SOLDERING  PORCELAIN  TEETH,  693 

usually,  from  the  shape  of  the  plate,  sufficiently  free.  This  I  re- 
gard the  simplest  and  best  method  to  prevent  warping  of  the 
plate,  so  often  caused  by  the  very  means  taken  to  prevent  it. 

"I  have  said  nothing  of  fastening  the  teeth  so  as  to  try  them  in 
the  mouth  before  soldering,  because  a  correctly  taken  articula- 
tion makes  it  unnecessary.  Those  who  prefer  to  do  so  can  secure 
the  teeth  with  cement  (resin  and  gutta-percha)  instead  of  wax 
after  grinding  ;  or,  perhaps  better  still,  after  making  the  tempo- 
rary plaster  investment,  unless  much  alteration  is  necessary." 

Mr.  Andrew  Wilson,  of  Scotland,  adopts  the  following  method 
of  backing  teeth  :  "  After  having  iiartially  fitted  the  tooth  to 
the  plate,  take  a  piece  of  platina  foil,  as  thick  as  can  be  used 
conveniently,  and  pressing  it  against  the  back  of  the  tooth,  per- 
forate it  where  it  is  marked  by  the  pins ;  then  cut  it  into  the 
required  shape  of  the  backing,  and  press  it  as  closely  as  possible 
to  the  back  of  the  tooth. 

"  It  will  now  be  requisite  to  apply  a  little  borax  to  the  platina 
pins  which  come  through  the  back,  and  placing  the  tooth  with  its 
face  downward  upon  a  thin  piece  of  pumice,  covered  with  dry 
plaster  of  paris,  put  several  pieces  of  gold  (according  to  the 
thickness  required)  upon  the  platina  back  ;  slowly  heat  it,  gradu- 
ally raising  the  heat  till  it  is  considered  safe  to  melt  the  gold  with 
the  blow-pipe,  when,  upon  continuing  the  blast,  the  gold  will 
rapidly  flow  over  the  whole  platina  surface,  uniting  so  firmly 
with  the  pins  in  the  tooth,  that  I  have  never,  during  eight  years' 
use,  seen  a  case  in  which  they  have  loosened,  even  where  there 
has  been  sufficient  violence  to  break  the  tooth. 

"  After  the  backing  has  been  run,  and  the  tooth  allowed  to 
cool  slowly,  it  is  filed  to  the  requisite  thickness  and  shape  ;  tooth 
and  backing  are  then  closely  fitted  and  finally  soldered  to  the 
plate.  In  arranging  the  teeth  on  the  plate  for  soldering,  I  use 
a  mixture  of  equal  parts  of  white  sand  and  plaster,  placing  a  thin 
strip  of  platina  on  the  outside  of  the  teeth,  with  a  layer  of  the 
above  mixture  on  both  sides  of  it,  so  that  should  the  plaster  crack 
in  soldering,  (although  it  is  less  liable  to  do  so  than  plaster 
alone,)  the  platina  may  keep  the  teeth  from  shifting  their  places. 
The  whole  time  occupied  in  heating  and  backing  a  tooth  is 
about  half  an  hour,  and  when  several  are  done  at  once,  a  little 
longer." 


604 


SOLDERING    PORCELAIN    TEETH. 


Instead  of  using  the  strip  of  platina  plate  to  prevent  the  teeth 
from  becoming  displaced,  in  case  the  plaster  cracks,  thin  sheet 
iron  or  iron  wire  may  be  used;  but  platina  is  undoubtedly  the 
neatest  and  has  the  advantage  of  being  indestructible;  it  may  be 
narrow  and  thin,  so  that  its  cost  would  form  no  objection  to  its 
use.  Mr.  Wilson's  method  might  be  improved,  first,  by  com- 
pletely fitting  the  tooth  before  backing ;  secondly,  by  running 
the  thin  platina  slip,  one  eighth  of  an  inch  down  on  the  plate,  to 
any  irregularities  of  which  it  can  be  quickly  burnished  down  by 
making  several  slits  in  the  edge.  This  would  secure  a  very  per- 
fect and  strong  attachment  to  the  plate. 

A  piece  invested  preparatory  for  soldering  and  placed  upon  a 
lump  of  solid  charcoal,  is  seen  in  Fig.  232. 

Fig.  232. 


Directions  for  aj)plying  bora.x  and  solder  have  already  been 
given.  Some  cut  the  solder  into  very  small  pieces;  others  use 
one  piece  to  each  tooth  at  its  ba.se,  and  a  second  for  the  pins  un- 
less  previously  soldered.     If  the  backinjrs  are  soldered  to   the 


FINISHING    PROCESS.  695 

teeth  beforehand,  a  more  fusible  grade  of  solder  should  be  used 
at  the  second  soldering. 

The  work,  as  before  stated,  must  be  gradually  and  thoroughly 
heated  up  before  directing  the  flame  upon  the  plate  or  backings. 

The  last  point  to  be  touched  with  the  flame  is  the  solder,  and 
this  not  before  a  slight  melting  of  the  edge  shows  that  it  is  just 
on  the  point  of  flowing.  If  every  preparation  for  soldering  has 
been  properly  made,  the  actual  flowing  of  the  solder  on  a  full 
piece  will  take  less  than  a  minute,  and  will  be  so  smooth  as  to  re- 
quire no  other  finish  than  the  Scotch-stone,  and  polishing  wheels. 
The  soldering  being  completed,  the  cover  should  be  placed  upon 
the  soldering  pan,  (Fig.  220,)  and  the  work  allowed  to  become 
quite  cold  before  removal. 

FINISHING  PROCESS. 

As  soon  as  the  piece  has  cooled  sufficiently,  after  the  process 
of  soldering  is  completed,  the  plaster  is  carefully  removed  from 
the  teeth;  the  piece  is  then  placed  in  a  glass  or  porcelain  vessel 
containing  a  mixture  of  equal  parts  of  sulphuric  acid  and  water, 
and  heat  applied.  As  soon  as  the  borax  (which,  by  the  process 
of  soldering,  has  lost  its  water  of  crystallization  and  assumed  a 
glassy  hardness)  is  decomposed,  the  vessel  is  removed  and 
allowed  slowly  to  cool.  This  process  is  termed  by  jewelers, 
pickling,  and  requires  from  ten  minutes  to  half  an  hour  for  its 
completion,  according  to  the  strength  of  the  acid  and  the 
quantity  of  vitrified  borax  on  the  plate.  After  this  is  decom- 
posed, the  acid  is  washed  from  the  piece,  which  can  be  more 
eff'ectually  done  by  the  use  of  heat  and  a  little  caustic  soda. 

In  removing  the  roughness  which  may  have  been  occasioned 
by  the  imperfect  fusion  and  unevenness  of  any  of  thn  pieces  of 
solder,  or  from  its  flowing  in  a  wrong  direction,  care  must  be 
taken  not  to  cut  away  too  much  of  the  plate.  For  this  purpose 
scrapers,  files  and  lathe-burs  are  used,  according  to  the  position 
and  quantity  of  surplus  solder.  After  the  work  has  been  made 
as  smooth  as  possible  with  scrapers,  &c.,  it  should  be  rubbed  with 
pieces  of  Scotch-stone  and  water  until  every  scratch  is  removed, 
and  then  polished  with  tripoli,  applied  by  means  of  oil  or  tallow 
to  a  brush  wheel,  (Fig.  2ii3,)  which  is  made  to  revolve  rapidly 


606  FINISHING    PROCESS. 

uffainst  the  work.  As  to  the  rapidity  with  which  a  lathe  should 
be  worked — drills  and  burs  require  a  slow  movement,  corundum 
wheels  a  quicker  one ;  rotten-stone  a  rapid  motion,  and  whiting 
or  rouge  the  most  rapid  of  all. 

The  piece  may  now  be  placed  in  a  porcelain  vessel  containing 
the  following  mixture  :  nitre,  two  ounces,  salt  and  alum,  each, 
one  ounce — dissolved  in  four  ounces  of  water.  After  boiling  for 
half  an  hour  in  this,  to  decompose  the  copper  from  the  surface 
layer  of  the  solder  and  plate,  it  is  boiled  a  few  minutes  in  a  mix- 
ture of  four  ounces  of  water,  with  one  ounce  of  caustic  soda,  for 
the  purpose  of  neutralizing  the  acid  formed  by  the  first  mixture, 
then  washed  with  a  brush  in  pure  water. 

The  removal  of  the  copper  from  the  surface  of  the  plate,  gives 
to  the  gold  the  beautiful  orange  hue,  which  is  its  natural  color, 
and  which  it  will  retain  until  the  friction  of  mastication  wears 
off  this  surface.  The  secretions  of  the  mouth  will  fail  to  tarnish 
it ;  and  it  will  be  free  from  the  disagreeable  taste  of  which  so 
many  complain,  who  wear  artificial  teeth  set  on  metallic  plate. 
The  process  of  finishing  may  be  completed  by  polishing  every 
part  of  the  lingual  surface  of  the  plate,  backings,  and  clasps, 
with  highly  tempered  and  finely  polished  steel  burnishers,  or  with 
rotten-stone  and  jeweler  s  rouge.*  If  burnishers  are  used,  they 
should  be  frequently  dipped  in  a  mixture  of  water  and  castile 
soap  ;  they  should  be  rubbed  backward  and  forward  in  the  same 
direction,  until  every  part  of  the  gold  exhibits  a  high  polish. 
Fig  233  Burnishers  of  different  shapes  may  be  re- 

quired  for    different    parts    of  the  work  : 
bloodstone  burnishers  4re  also  used. 

A  large  piece,  however,  can  be  polished  in 
much  less  time,  if  not  more  perfectly  with  a 
revolving  brush,  like  the  one  represented  in 
Fig.  233.  The  brush  should  be  set  on  the 
spindle  of  the  lathe,  then  lightly  smeared 
with  suet,  by  holding  a  small  piece  against 
It  while  it  is  revolving.     The  rotten-stone  is  applied  in  the  same 

*  Jeweler'i  rouge  is  made  by  dissolving  copperas  in  water,  filtering  the  solution, 
and  adding  a  filtered  solution  of  pearlash  or  subearbonate  of  soda,  as  long  as  any 
ecdiment  falls.  The  liquor  is  again  filtered,  and  the  sediment  left  on  the  filter  washed 
by  running  clean  water  through  it,  and  then  calcined  until  it  is  of  a  scarlet  color.— 
Chemistry  of  the  Arts,  vol.  2,  p.  529. 


FINISHING    PROCESS.  697 

manner,  and  with  the  brush  thus  charged,  the  polishing  may 
commence,  but  the  plate  must  not  be  exposed  too  long  to  the 
friction,  as  it  will  rapidly  wear  away  the  pure  gold  surface 
brought  out  by  the  pickle.  Some  use  only  the  burnisher  or 
rouge  after  pickling.  Tripoli  has  a  sharper  grit  and  cuts  more 
rapidly  than  the  ordinary  rotten-stone  prepared  for  daguerreo- 
typists'  use,  but  the  latter  gives  a  very  smooth  surface,  and  will, 
in  most  cases,  give  a  sufficiently  brilliant  finish  without  rouge. 

But  a  very  high  "watch-case"  finish  can  only  be  given  by 
the  very  rapid  revolution  of  wheels  or  buffers,  charged  with 
finest  quality  of  rouge,  wet  with  alcohol.  The  piece  must  be 
previously  washed  with  soap  and  water,  so  as  to  remove  every 
trace  of  oil.  Sometimes  the  rouge  is  applied  on  a  piece  of  soft 
buckskin,  wrapped  or  sewed  around  small  blunt-pointed  pieces 
of  wood. 

Upon  the  insertion  of  partial  pieces  with  clasps  prepared  in  the 
manner  just  described,  it  may  possibly  become  necessary  to  make 
some  little  alteration  in  the  adaptation  of  the  clasps.  This,  the 
operator  can  do,  with  a  pair  of  common  pliers ;  and  it  should  be  borne 
in  mind  that  clasps  must  never  be  so  applied  as  to  prevent  the 
patient  from  removing  and  replacing  the  piece  at  pleasure. 
He  should  be  directed  to  do  this  two  or  three  times  every  day,  and 
each  time,  to  clean  thoroughly  the  teeth  to  which  the  clasps  are 
applied,  and  it  may  be  advisable  for  the  artificial  piece  to  be  taken 
out  every  night  on  going  to  bed,  and  remain  out  until  morning. 
This  should  also  be  done  with  pieces,  whether  partial  or  entire, 
which  depend  for  their  adhesion  upon  a  vacuum  cavity,  so  as  to 
give  rest  to  the  mucous  membrane  and  permit  the  swelling  oppo- 
site the  cavity  to  subside.  But  pieces  that  are  retained,  simply, 
by  the  accuracy  of  their  adaptation  may  be  worn  night  and  day, 
and  this  will  ordinarily  be  found  most  agreeable  to  the  patient. 
A  beautiful  style  of  tooth  made  by  Ash,  of  London,  is  secured 
to  the  plate  by  gold  pins,  fastened  to  the  teeth  by  hard-solder, 
and  then  secured  by  soft-solder  to  the  gold  tube  running  through 
the  axis  of  the  tooth.  The  composition  of  the  tooth  renders 
this  modification  in  the  mode  of  attachment  necessary,  as  they 
will  not  stand  a  soldering  heat. 

A  substitute  for  the  incisors  and  cuspids,  thus  mounted,  is 

45 


698 


FINISHING    PROCESS. 


Fig.  234. 


represented  in  Fig.  234,  copied  from  the  work  of  Dr.  James  Robin- 
son. This  engraving  will 
convey  a  sufficiently  cor- 
rect idea  of  the  method  of 
attaching  the  English  min- 
eral or  porcelain  teeth  to  a 
metallic  base,  to  render  any 
other  description  unneces- 
sary. The  fastening  by  pins  will  prove  serviceable  for  blocks  ; 
but  for  single  teeth,  metallic  backings,  riveted  and  soldered 
after  the  American  method,  as  above  directed,  is  a  far  more  se- 
cure method  of  attachment. 

As  the  improvements  in  ceramic  dentistry  have  so  entirely 
superseded  the  use  of  natural  teeth,  and  since  these  are  open  to 
serious  objections,  previously  stated,  it  is  not  thought  necessary 
to  give  any  description  of  the  methods  once  employed  for  mount- 
ing them.  We  shall  next  proceed  to  notice  the  manner  in  which 
artificial  substitutes  are  retained  in  the  mouth  :  also  some  of  the 
modifications  of  form,  &c.,  required  by  the  special  conditions  of 
individual  cases ;  giving  a  sufficient  variety  to  prepare  the  student 
for  any  case  that  may  come  before  him. 


CHAPTER    THIRTEENTH. 
ARTIFICIAL  TEETH  RETAINED  BY  SPIRAL  SPRINGS. 

A  DOUBLE  set  of  artificial  teeth  (by  which  is  meant  a  substi- 
tute for  all  or  the  greater  part  of  the  natural  teeth  of  both  jaws) 
was  at  one  time  universally,  though  now  very  rarely,  retained  in 
place  in  the  mouth  with  spiral  springs.  When  correctly  con- 
structed, and  applied  under  favorable  circumstances,  they  are 
valuable  substitutes  for  the  natural  organs;  but  when  badly 
constructed,  and  applied  under  unfavorable  circumstances,  they 
are  productive  of  more  or  less  inconvenience  and  annoyance  to 
the  patient. 

It  often  happens  that  the  loss  of  the  teeth  is  occasioned  by 
disease  in  the  gums  and  alveolar  processes ;  in  which  case,  the 
latter  are  so  much  wasted  and  destroyed  that  the  ridge  is 
scarcely  perceptible,  and  is  sometimes,  in  the  lower  jaw,  covered 
with  loose  folds  of  mucous  membrane.  The  pressure  of  spiral 
springs  upon  these  folds  is  apt  to  produce  irritation ;  so  that  it 
is  very  difficult  to  give  to  lower  pieces,  in  such  cases,  much 
stability.  This  total,  or  almost  total,  absence  of  any  alveolar 
ridge  in  both  upper  and  lower  jaws  is  regarded  by  many  as 
demanding  the  use  of  spiral  springs.  In  some  upper  cases  the 
palatine  arch  is  a  plane  from  one  side  to  the  other,  and  in  a  very 
few  it  is  actually  convex;  the  attachment  of  the  muscles  being 
so  close  down  upon  the  edge  of  the  alveolar  border  as  to  permit 
scarcely  any  plate  to  be  turned  up.  The  great  difficulty  in  the 
way  of  securing  such  plates  by  atmospheric  pressure,  is  the 
almost  impossibility  of  preventing  lateral  motion.  A  sharply 
defined  vacuum  cavity  will  sometimes  meet  the  difficulty ;  but  all 
mouths  will  not  bear  the  irritation  of  this,  and  there  is  no  alter- 
native but  to  use  spiral  springs. 

A  more  modern  application  of  spiral  springs  is  their  tempo- 
rary use  in  pieces  made  very  soon  after  the  extraction  of  the 
teeth.     The  dentist  not  wishing,  for  several  reasons,  to  conform 


700 


ARTIFICIAL   TEETH    RETAINED    BY    SPRINGS. 


the  plate  to  all  the  irregularities  of  the  gum  at  this  stage  of 
absorption,  pares  down  on  the  model  the  prominences,  and 
fills  up  the  hollows  of  the  ridge.  This  necessarily  destroys  the 
fit  of  the  plate,  and  the-  pressure  of  springs  is  necessary  until 
the  mouth  has,  by  absorption,  adapted  itself  to  the  plate :  they 
may  then  be  taken  off. 

The  upper  plate  may  be  about  one  inch  in  width,  and  made  of 
twentv-carat  2old;  the  lower  should  be  as  wide  as  the  ridge  will 
admit  of  its  being  made,  and  twice  as  thick  as  the  upper,  and 
the  gold  at  least  twenty-two  carats  fine. 

After  having  obtained  a  correct  antagonizing  model,  the  ope- 
rator places  on  each  plate  a  rim  of  bees-wax,  against  which  the 
teeth  are  arranged  as  he  selects  them  ;  beginning  with  the  cejLtral 
incisors,  he  may  adapt  first  the  upper,  then  the  lower,  next  the 
laterals,  afterward  the  cuspids  and  bicuspids,  and,  lastly,  the 
first  and  second  molars — twenty-eight  being  the  number  usually 
employed  for  an  artificial  set.  After  the  teeth  have  been  ground, 
arranged,  and  fitted  to  the  plates,  the  gold  backings  are  to  be 
attached,  and  the  piece  then  invested  with  plaster ;  the  wax  is 
next  removed,  and  the  process  of  soldering  and  finishing  per- 
formed in  the  manner  already  described. 

But  before  the  teeth  are  soldered  on,  the  attachments  or 
standards  for  the  springs  are  made  fast  to  the  outer  edge  of  the 
plates  on  each  side,  resting  against  the  second  bicuspids,  or 
partly  between  them  and  the  first  molars.  The  kind  of  attach- 
ment which  the  author  prefers,  so  regulates  the  motion  of  the 
sprmgs,  that  they  are  prevented  from  coming  in  contact  with 
the  outer  surface  of  the  alveolar  ridge  beyond  the  plate,  or  from 

turning  out  toward  the  cheek, 
and  irritating  the  mucous  mem- 
brane.  The  construction  of  the 
standards,  eyelets  and  spiral 
springs  is  so  plainly  exhibited 
on  the  next  page  (Fig.  236), 
that  any  verbal  description  is 
deemed  unnecessary. 

The  manner  in  which  the 
springs  act  may  be  seen  in  Fig. 
235,  by  which  it  will  be  per- 


FiG.  235. 


ARTIFICIAL    TEETH    RETAINED    BY    SPRINGS.  701 

ceived  the  upper  and  lower  dentures  are  constantly,  but  gently 
pressed  against  the  parts  on  which  they  rest.. 

Spiral  springs  are  most  conveniently  purchased  at  the  depots; 
but  they  may  be  made  by  the  simple  apparatus  shown  in  Fig. 
187.     The  length  of  the  springs  must  be    determined  by  the 

Fig.  236. 


distance  of  the  jaws  from  each  other  when  the  mouth  is  opened ; 
it  being  in  some  cases  necessary  to  have  them  much  longer  than 
in  others.  The  usual  length,  however,  is  from  an  inch  and  a 
half  to  two  inches. 

It  often  happens  that  six  or  eight  teeth  in  the  front  part  of 
i'ae  mouth,  in  the  lower  jaw,  remain  healthy  and  firmly  fixed  in 
their  sockets,  after  all  the  other  teeth  are  lost.  In  this  case, 
the  lower  plate  may  be  so  constructed  as  to  cover  the  vacant 
portions  of  the  alveolar  ridge,  fitting  its  upper  and  inner  surface 
behind  the  remaining  natural  teeth.  This  part  of  the  plate  is 
strengthened  by  soldering  to  it  another  plate  of  equal  or  even 
greater  thickness. 

But  when  the  lower  incisors,  cuspids,  and  two  of  the  bicuspids 
remain,  it  is  perhaps  better  to  dispense  with  the  molars  and 
remaining  bicuspids,  than  encumber  this  part  of  the  mouth  with 
an  artificial  substitute.  When  there  are  but  six  teeth  remaining 
in  the  lower  maxilla,  it  is  thought  by  some  practitioners  better 
to  extract  them  and  apply  an  entire  denture,  as  it  is  sometimes 
almost  impossible  to  replace  the  others  in  such  a  way  as  to  render 
them  serviceable  while  the  front  part  of  the  jaw  is  occupied  with 
natural  teeth.  The  extraction  of  four  or  even  six  front  lower 
teeth  remaining,  is  perfectly  justifiable  under  certain  circum- 
stances— where  they  are  much  decayed,  or  are  elongated  by 
ossific  deposit,  or  loosened  by  alveolar  absorption,  or  project 
outward  so  much  as  to  make  the  articulation  of  the  upper  teeth 
very  disfiguring.  A  partial  lower  piece  can  be  made  under  these 
circumstances,  and  spiral  springs  attached  if  required;  but  the 
work  will  not  give  much  satisfaction  to  the  patient,  or  add  much 
to  the  reputation  of  the  operator. 


702         ARTIFICIAL   GUM-TEETH,    SINGLE    OR   IN   SECTIONS. 


ARTIFICIAL  GUM-TEETH,  SINGLE  OR  IN  SECTIONS. 

The  loss  of  the  teeth  is  followed,  sooner  or  later,  by  the  ab- 
sorption of  more  or  less  of  the  alveolar  border.  Much  of  this 
absorption  not  unfrequently  precedes  the  loss  of  the  teeth ;  and 
in  extraction  it  becomes  at  times  necessary  to  destroy  a  part  of 
the  alveolus.  In  furnishing  a  substitute,  therefore,  for  the  teeth, 
it  often  becomes  necessary,  for  the  restoration  of  the  contour  of 
the  face,  to  replace  the  missing  alveolus  :  for  doing  this  several 
methods  have  been  adopted. 

When  ivory  was  employed  for  artificial  teeth,  as  a  base  for 
the  support  of  the  teeth,  it  was  carved  in  such  a  manner  as  to 
imitate  the  shape  of  the  gums,  and  afterwards  colored.  But  the 
use  of  hippopotamus  teeth  or  elephant-ivory,  for  purposes  of  this 
kind,  has  been  wholly  or  very  nearly  abandoned. 

Raised  plates — that  is,  plates  made  double  over  the  ridge, 
with  a  space  between — have  also  been  employed,  and  these  may 
be  made  to  answer  a  very  good  purpose;  but  improvements  in 
the  manufacture  of  porcelain  teeth  have  supplied  a  much  better 
substitute  for  the  alveolar  border  and  gums.  Porcelain  teeth 
may  be  manufactured  either  singly  or  in  blocks,  colored  and 
enameled  on  the  exterior  or  labial  surface  above  the  tooth,  so  as 
to  form  a  most  excellent  substitute  for  the  lost  structures,  and 
imitating  nature  so  closely  as  almost  to  preclude  the  possibility 
of  detection.  It  is  customary  among  dentists  manufacturing 
their  own  porcelain  or  mineral  teeth,  to  mould  them  in  blocks  of 
three,  four  or  five  teeth.  Comparatively  few  dentists  possess 
the  necessary  knowledge,  practical  experience,  or  apparatus  for 
doing  this;  but  there  are  some  cases  in  which  they  cannot  be 
advantageously  dispensed  with.  In  a  subsequent  chapter,  the 
method  of  making  and  mounting  block  teeth  will  be  described. 

A  practical  knowledge  of  block  carving  is  of  great  service  to 
the  dentist  who  has  the  peculiar  talent  which  it  requires,  and  the 
time  at  his  command  which  its  prosecution  demands.  But  like 
the  manufacture  of  single  teeth,  this  is  rapidly  passing  out  of 
the  hands  of  the  professional  man  into  those  of  the  manufac- 
turer. The  consequence  is  that  the  variety  and  beauty  of  the 
blocks  offered  for  sale  are  so  rapidly  improving,  that  the  same 


ARTIFICIAL    GUM-TEETH,    SINGLE    OR    IN    SECTIONS.         703 

necessity  is  not  felt  as  formerly  to  devote  so  many  months  to  the 
study  of  ceramic  dentistry.  Teeth,  with  artificial  gums  to  supply 
the  alveolar  loss,  are  made  either  singly  or  in  sections  of  two, 
three  or  four. 

A  little  more  time  and  tact  are  required  in  fitting  the  single 
gum  teeth  to  each  other,  and  to  the  plate,  than  in  adapting  blocks 
or  sections ;  but  when  properly  adjusted  and  attached  to  the 
plate,  they  answer,  in  very  many  cases,  almost  as  good  a  pur- 
pose ;  and  if  by  any  accident  one  or  two  of  the  teeth  are  broken, 
they  may  be  more  easily  replaced.  In  the  construction  of  a 
piece  composed  of  single  teeth,  they  should  be  fitted  to  each 
other  and  the  plate  in  the  most  perfect  and  accurate  manner,  so 
that  no  lodgments  may  be  afforded  for  particles  of  food  or  ex- 
traneous matter  of  any  kind.  One  point,  however,  must  be 
remembered,  which  has  been  already  alluded  to.  In  soldering, 
the  metal  expands,  while  the  teeth  held  in  the  investment  are 
brought  closer  together  by  its  contraction,  and  in  this  slightly 
altered  position  they  are  soldered  to  the  plate.  The  contraction 
of  the  plate  on  cooling  is  irresistible,  and  may  result  in  one  or  both 
of  two  accidents — chipping  off  the  brittle  edges  of  the  teeth  thus 
brought  too  closely  together,  or  warping  the  plate  because  of  the 
resistance  which  the  teeth  or  blocks  ofi'er  to  the  contraction  of 
the  plate.  The  thinnest  letter-paper  slipped  between  the  side 
joints  will  suffice  to  prevent  these  accidents.  In  Figs.  237,  238, 
are  represented  atmospheric  pressure  substitutes  for  all  the  teeth 

Fig.   237.  •  Fio.   238. 


V,* 


of  the  upper  jaw,  composed  of  single  gum  teeth,  mounted  upon 
broad  plates.  In  the  latter,  the  outer  edge  of  the  plate  is  turned 
down  on, the  front  edge  of  the  gums,  both  for  strength  and  orna- 
ment. 

Usually,  in  first  or  temporary  pieces,  and  sometimes  after  the 
alveolar  absorption  is  completed,  the  fullness  of  the  gum  is  such 


704         ARTIFICIAL    GUM-TEETH,    SINGLE    OR    IN    SECTIONS. 

as  to  forbid  the  addition  of  an  artificial  gum  to  the  six  or  eight 
front  teeth.  In  such  cases  the  plate  must  be  cut  away  from  the 
front  of  the  ridge  as  far  as  the  first  or  second  bicuspid,  and  the 
teeth  frround  with  great  accuracy  to  fit  the  gum  itself.  Single 
plain  teeth  will  usually  be  best  adapted  to  such  cases ;  but  an 
excellent  effect  can  sometimes  be  produced  by  grinding  a  block, 
when  the  shade  of  gum  is  well  matched,  to  fit  directly  upon  the 
natural  gum. 

It  has  been  also  recommended  to  cover  the  anterior  margin  of 
the  plate  and  interspaces  between  the  teeth  with  a  terra-metallic 
paste,  fusible  at  a  very  low  temperature,  and  afterwards  covered 
with  gum  enamel.  The  following  formula  is  given  by  M.  Dela- 
barre  for  this  purpose:  Porcelain  paste  1  oz.,  white  silex  half  oz., 
any  oxide  10  grs.,  and  a  sufficient  quantity  of  calcined  gypsum,  to 
give  to  it  the  necessary  degree  of  fusibility.  As  a  suitable  enamel, 
Desirabode  recommends,  feldspar  2  drachms,  oxide  of  gold  6  grs., 
kaolin  6  grs.  But  neither  of  these  formulae  can  be  used  on  gold 
plate,  nor  in  connection  with  American  porcelain  teeth,  as  too 
high  a  heat  is  required  for  their  fusion.  Drs.  Hunter  and  Allen, 
however,  have  succeeded  in  making  a  silicious  composition,  which 
can  be  used  on  gold  slightly  alloyed  with  platina.  That  it  is 
quite  possible  to  make  a  porcelain  enamel  which  will  fuse  below  the 
melting  point  of  even  eighteen-carat  gold  is  known  to  every  jew- 
eller. But  the  serious  difficulty  in  all  such  enamels  is  their  frail 
and  brittle  nature;  hence  none  are  now  used  to  any  extent 
except  that  form  of  enamel  known  as  "Allen's  Gum,"  or  the 
"  Continuous  Gum,"  which  fuses  above  the  melting  point  of  pure 
gold.    This  process  will  be  described  in  the  seventeenth  chapter. 


CHAPTER    FOURTEENTH. 
ARTIFICIAL  TEETH  RETAINED  BY  CLASPS. 

In  supplying  the  loss  of  natural  teeth  with  artificial  substi- 
tutes, the  ingenuity  and  skill  of  the  dentist  are  often  taxed  to 
their  greatest  extent.  No  two  cases  are  precisely  alike,  and, 
therefore,  no  directions  can  be  given  upon  the  subject  which  it 
will  not  often  be  necessary  to  modify.  The  illustrations,  how- 
ever, which  follow  will,  we  trust,  from  their  variety,  enable  the 
practitioner  to  construct  an  efficient  and  useful  substitute  for  any 
teeth,  the  loss  of  which  he  may  be  called  upon  to  replace. 

POSITION  AND  SHAPE  OF  TEETH  MOST  SUITABLE  FOR  CLASPS 

—MEANS  NECESSARY  TO  PREVENT  THE  INJURY  RESULT- 
ING FROxM  THEIR  USE. 

Some  teeth,  owing  to  their  situation  in  the  dental  arch  and 
the  shape  of  their  crowns,  offer  a  more  secure  means  of  attach- 
ment to  a  dental  substitute  retained  in  the  mouth  by  clasps  than 
others.  In  selecting  those  which  are  to  be  used  for  this  pur- 
pose, the  exercise  of  some  judgment  is  often  called  for.  There 
are  many  circumstances,  however,  which  should  influence  the 
decision  of  the  dentist  in  this  matter.  Some  of  these  we  shall 
now  proceed  to  notice. 

As  we  have  stated  in  another  place,  the  first  molars  in  the 
upper  jaw,  when  sound  and  securely  articulated,  offer  a'better 
means  of  support  than  any  of  the  other  teeth,  and  when  they 
can  be  conveniently  employed  for  this  purpose,  should  always 
be  preferred.  But  when,  from  loss,  decay  or  defective  shape, 
these  cannot  be  used,  the  second  bicuspids  or  second  molars  are 
to  be  preferred ;  the  bicuspids  having  the  advantage  so  far  as 
regards  position,  but  the  molars  being  larger  and  firmer.  Next 
to  these  in  order  of  choice  come  the  first  bicuspids,  which  are  in- 
ferior to  the  second,  chiefly  because  they  cannot  be  clasped  so 


70t)  TEETH  SUITABLE  FOR  CLASPING. 

fullv  without  exposing  the  metal  of  the  clasp.  Unless  large, 
sound  and  .<trong,  the  bicuspids  should  not  be  depended  on  for 
the  retention  of  a  larce  number  of  teeth  ;  but  for  incisors  alone, 
they  are  the  best  clasp-teeth,  owing  to  their  position.  In  this 
latter  respect,  the  worst  teeth  in  the  mouth  are  the  third  molars. 
Their  bad  position,  their  liability  to  decay,  and  their  frequent 
conical  shape  make  these  the  most  undesirable  of  all,  except  the 
six  front  teeth,  for  the  attachment  of  clasps.  Still,  if  sound, 
firmly  articulated  and  well  shaped,  they  may,  as  a  last  resort, 
be  used. 

The  crowns  of  the  cuspids  being  of  a  conical  shape,  are  wholly 
unsuited  for  the  retention  of  clasps,  and,  consequently,  should 
never  be  used  for  this  purpose.  There  are  cases,  however,  in 
which  it  is  considered  by  some  to  be  absolutely  necessary  to 
apply  clasps  to  these  teeth;  as,  for  example,  when  the  loss  of  an 
incisor  is  to  be  replaced  with  a  substitute  attached  to  a  narrow- 
plate,  and  where  none  of  the  back  teeth  remain  or  are  in  a  con- 
dition to  be  used  as  a  means  of  support  to  the  plate.  In  this 
case,  the  clasps  should  be  narrow,  and  adapted  with  the  greatest 
accuracy.  This  becomes  the  more  essential,  as  it  is  necessary 
that  they  should  be  short  to  prevent  being  seen,  and  as  no  hold 
can  be  obtained  upon  the  lingual  side  of  the  tooth.  They  should 
also  be  applied  near  to  the  gums,  but  not  so  near  as  to  touch  and 
irritate  them,  or  the  cementum  at  the  neck  of  the  tooth. 

The  incisors  are,  of  all  the  teeth,  the  least  suited  for  the  at- 
tachment of  a  dental  substitute.  It  is  exceedingly  difficult  to 
apply  clasps  to  these  teeth  in  such  a  manner  as  to  retain  even  a 
single  tooth  with  sufficient  stability  to  be  worn  with  any  degree 
of  comfort.  We  remember  once  to  have  seen  a  case  in  which  a 
central  incisor  (natural  tooth)  was  inserted  and  kept  in  place  by 
a  gold  wire  projecting  from  each  side  of  the  tooth  into  holes 
drilled  into  the  adjoining  teeth.  A  stage  of  dental  progress 
that  permitted  such  a  process,  might  also  have  allowed  the  clasp- 
ing of  incisors.  But  we  know  of  no  possible  circumstances  that 
will  justify,  in  the  present  state  of  dental  art,  the  clasping  of 
the  four  (we  were  about  to  say  the  six)  front  teeth. 

There  are  many  circumstances,  besides  position  and  shape, 
which  it  is  necessary  to  take  into  consideration  in  the  selection 
of  teeth  to  be  used  as  a  means  of  support  for  artificial  teeth. 


TEETH    SUITABLE    FOR    CLASPING.  707 

For  example,  a  space  should  never  be  filed  between  two  sound 
molar  or  bicuspid  teeth  for  the  purpose  of  applying  a  clasp,  if 
there  is  another  tooth  around  which  it  can  be  placed  without  this 
operation.  The  liability  of  the  tooth  to  decay,  around  which  a 
clasp  is  applied,  is  always  greatly  increased  by  the  removal  of 
any  portion  of  its  enamel ;  hence,  the  separation  of  two  teeth 
with  a  file,  with  a  view  to  the  application  of  a  clasp  to  one  of 
them,  should  never  be  resorted  to. 

A  clasp  should  never  be  applied  to  a  loose  tooth,  or  to  one 
situated  in  a  diseased  socket,  or  which  is  so  much  affected  by 
caries  as  to  render  its  perfect  restoration  and  permanent  preser- 
vation impracticable;  and  when  none  but  such  can  be  had,  the 
proper  course  to  pursue  is,  either  to  extract  every  tooth  in  the 
jaw,  and  replace  the  loss  of  the  whole  with  an  entire  upper  set, 
or  to  replace  the  missing  teeth  upon  an  atmospheric  pressure 
plate.  The  application  of  clasps  to  diseased  or  loose  teeth  al- 
ways aggravates  the  morbid  condition  of  the  parts,  and  causes 
the  substitute  which  they  keep  in  place  to  become  a  source  of 
annoyance  to  the  patient.  Besides,  such  teeth  can  be  retained 
in  the  mouth  only  for  a  short  time,  and  when  they  give  way, 
the  artificial  appliance  becomes  comparatively  or  entirely  useless; 
and  even  before  their  loss,  it  is  not  held  firmly  in  its  place,  but 
is  moved  up  and  down  by  the  action  of  the  lips  and  tongue. 
Thus  not  only  is  its  presence  open  to  the  observation  of  the  most 
careless  observer,  but  this  motion  is  rapidly  destructive  to  all 
the  teeth  near  or  against  which  the  piece  comes. 

In  the  lower  jaw,  parts  of  sets  are  much  less  frequently  called 
for  than  in  the  upper,  and  when  they  are,  the  use  of  clasps  may 
be  often  dispensed  with  altogether.  But  it  'sometimes  becomes 
necessary  to  use  them,  and,  as  a  general  rule,  they  can  be  more 
conveniently  applied  to  the  bicuspids  than  to  the  molars  or  cus- 
pids. A  clasp  can  seldom  be, applied  advantageously  to  a  lower 
molar.  The  lower  front  teeth  are  least  liable  to  decay  of  any 
in  the  mouth,  and,  therefore,  do  not  require  replacement,  except 
in  full  sets,  unless  lost  by  a  blow  or  by  the  destructive  action  of 
salivary  calculus.  A  partial  lower  front  piece  calls  for  clasps 
or  stays;  but  other  partial  lower  pieces  (replacing  bicuspids  and 
molars)  should  not  depend  for  their  stability  upon  any  remaining 
bicuspid  or  cuspid. 


708  MEANS   TO    PREVENT   INJURY   FROM    CLASPS. 

If  die  injurious  effects  liable  to  result  from  the  application  of 
clasps  to  teeth  could  not,  in  any  way,  be  counteracted,  dental 
substitutes,  maintained  in  the  mouth  by  this  means,  would,  in 
the  majority  of  cases,  be  productive  of  more  injury  than  benefit. 
But,  fortunately,  they  may,  in  most  cases,  to  some  extent  at 
least,  be  prevented.  They  are  not  produced,  as  many  have  er- 
roneously supposed,  solely  by  the  mechanical  action  of  the  clasps 
upon  the  teeth,  but  also  by  the  chemical  action  of  the  secretions 
of  the  mouth  and  decomposing  particles  of  food. 

The  cause  of  this  destructive  action,  then,  being  chemical,  as 
well  as  mechanical,  the  method  of  measurably  preventing  its 
deleterious  effects  is  obvious,  and  is  two-fold:  First,  to  prevent 
the  chemical  action,  the  frequent  removal  of  the  artificial  teeth, 
and  thoroughly  cleansing  the  natural  organs  used  as  a  means  of 
support  for  them.  This  should  be  done  every  night  and  morn- 
ing, and  after  each  meal.  For  which  purpose,  a  brush  and  waxed 
floss-silk  may  be  employed,  and  the  teeth  rubbed  until  every 
particle  of  clammy  and  vitiated  mucus  and  foreign  matter  is  re- 
moved. The  inner  surfaces  of  the  clasps,  too,  should  be  freed 
from  all  impurities,  and  the  whole  piece  cleansed  with  a  brush 
and  water.  Secondly,  to  prevent  or  lessen  the  mechanical  ac- 
tion, the  clasp  should  fit  with  great  accuracy  and  around  the 
parts  of  the  tooth  protected  with  hard  enamel;  and  the  whole 
piece  should  have  such  an  accuracy  of  adaptation  as  to  prevent 
that  motion  of  the  clasp  which  inevitably  gives  rise  to  a  destruc- 
tive friction  upon  the  tooth.  We  have  elsewhere  spoken  of  other 
injurious  consequences  of  fitting  clasps  imperfectly  or  placing 
them  close  upon  the  gums  or  exposed  necks.  Rapid  decay  and 
breaking  off  of  the  teeth,  inflammation  of  the  gums,  of  the  al- 
veolo-dental  periosteum,  destruction  of  the  alveoli,  and  loosen- 
ing of  the  teeth  are  among  the  common  results  of  the  clasping 
of  teeth  as  it  is  too  often  practiced.  Consequences  which  have 
led  many  to  too  unqualified  a  condemnation  of  this  method, 
which,  in  certain  cases,  is,  if  properly  executed,  the  best  and 
most  durable  way  in  which  a  partial  piece  can  be  secured. 


J 


CENTRAL    INCISOR   WITH    ONE    CLASP.  709 


CENTRAL  INCISOR  WITH  ONE  CLASP. 

The  usual  method  of  applying  a  central  incisor  on  a  metallic 

base  consists  in  extending  the  plate  over  the  palatine  arch  to 

the   second  bicuspid  or  first  molar   on  each 
.  ,         ^     ,  1  T  .  .      .         ,  Fig.  239. 

Side  of  the  mouth,  and  securing  it  m  the 
mouth  by  two  clasps;  but  it  is  not  always 
necessary  to  do  this.  It  can  often  be  secure- 
ly and  firmly  fixed  by  extending  the  plate 
back  on  one  side  only,  and  clasping  it  to  a 
single  bicuspid  or  molar.  A  piece  secured 
in  this  manner  may  be  frequently  worn  with 
comfort  and  satisfaction  for  years.  The  au- 
thor has  very  frequently  applied  one  tooth  in 
this  way,  when  he  found  it  necessary  to  use  clasps,  and  even 
two  teeth  may  often  be  securely  retained  with  one  clasp.  In 
extending  the  plate  over  the  arch  of  the  mouth,  it  should  never 
be  fitted  closely  around  the  necks  of  the  teeth  behind  which  it 
passes,  for  the  reason  that  it  is  liable  to  irritate  and  inflame  the 
apices  of  the  gums,  and  to  irritate  also  the  sensitive  neck  of  the 
tooth,  and  sometimes  even  the  alveolo-dental  periosteum.  The 
author,  in  common  with  other  dentists,  was  in  the  habit  of  doing 
this  for  a  long  time ;  but,  observing  the  bad  effects  produced  by 
it,  he  abandoned  the  practice  many  years  ago,  and  has  since,  in 
nearly  all  cases,  left  a  space  of  never  less  than  an  eighth  of  an 
inch,  and  often  much  more,  between  the  plate  and  the  teeth  be- 
hind which  it  passed.  A  correct  idea  may  be  formed  of  the 
manner  in  which  a  central  incisor  is  thus  arranged  by  an  exami- 
nation of  Fig.  239.  It  will  be  seen  that  the  lateral  curve  of 
the  plate  is  in  the  opposite  direction  from  the  curvature  of  the 
dental  arch,  thus  giving  proximity  to  the  teeth  only  where  it  is 
unavoidable.  A  lateral  incisor,  cuspid  or  bicuspid  may  be  ap- 
plied in  the  same  way;  and  if  the  second  bicuspid  or  first  molar 
is  unfit,  from  its  shape  or  from  decay,  to  be  clasped,  the  plate 
may  be  extended  to  the  second  molar,  or  it  may  be  even  carried 
across  the  mouth,  and  clasped  to  a  tooth  on  the  opposite  side. 


710  TWO   CENTRAL   INCISORS   WITH    CLASPS. 


CENTRAL  INCISOR  WITH  TWO  CLASPS. 

Cases  will  frequently  occur   in  wliich  it  may  be  necessary  to 

employ  two  clasps   for   the 
Fig.  240.  ^      «  .      ,      .      . 

support  01  a  single  incisor. 

The  accompanying  cut  (Fig. 
240)  will  indicate  the  de- 
scription of  plate  most  pro- 
per to  be  used.  The  plate, 
as  here  shown,  is  extended 
back  to  the  first  molar  on 
each  side,  to  which  it  is  se- 
cured by  suitable  clasps.  When  two  clasps  are  used,  it  is  not 
essential  that  so  much  of  the  tooth  should  be  grasped  by  the 
clasp.  In  some  cases,  the  piece  will  be  firmly  retained  by  short 
clasps,  bearing  against  the  lingual  third  of  the  tooth,  provided 
the  surface  is  so  shaped  as  to  allow  their  retention.  Such  par- 
tial clasps  are  called  stays,  and  are  often  used  in  connection 
with  an  atmospheric-pressure  plate  to  prevent  lateral  motion. 

When  the  patient  is  very  intolerant  of  the  presence  of  much 
metal  in  the  mouth,  one  or  two  teeth  may  sometimes  be  securely 
inserted,  as  suggested  by  Dr.  Maynard,  upon  a  T-shaped  plate. 
The  cross-piece  one-fourth  to  three-eighths  of  an  inch  wide,  fit- 
ting the  arch  from  bicuspid  to  bicuspid ;  the  slip  to  which  the 
tooth  is  attached  being  soldered  to  the  centre,  and  also  fitting 
the  arch.  Such  a  piece,  well  made,  will  resist  considerable  trac- 
tion upon  the  incisor.  Owing  to  the  peculiarity  of  its  shape, 
the  attempt  to  draw  down  the  tooth  springs  the  transverse  slip 
of  metal,  and  causes  it  to  bind  upon  the  bicuspids. 

TWO  CENTRAL  INCISORS  WITH  CLASPS. 

In  the  application  of  the  two  upper  central  incisors  on  plate, 
two  clasps,  one  on  each  side,  will  ordinarily  be  found  necessary, 
although  they  can  sometimes  be  securely  and  steadily  held  in 
place  with  one.  The  shape  and  general  arrangement  of  the  plate 
is  the  same  as  in  the  last  case,  but  it  should  be  a  little  wider 
on  account  of  the  increased  strain  caused  by  the  additional  tooth. 


INCISORS    AND    CUSPIDS    WITH    CLASPS. 


711 


The  second  bicuspids  or  first  molars  are  the  most  suitable  teeth 
for  clasping,  so  far  as  regards  position:  but  if  caries,  or  defect 
in  shape,  or  the  absence  of  Pj^  241. 

these  teeth  prevent  their 
use,  the  first  bicuspids  or 
second  molars  must  be  used, 
whichever  may  be  best  suit- 
ed to  give  a  firm  support. 
In  Fig.  241  the  plate  is  rep- 
resented as  extending  to  the 
first  molar  on  each  side. 

It  not  unfrequently  happens  that  one  or  two  inferior  incisors 
are  missing — the  result  either  of  accident,  or  from  absorption 
of  the  alveoli.  They  may  be  replaced  by  attaching  the  artifi- 
cial teeth  to  a  narrow  plate,  shaped  somewhat  as  in  the  upper 
jaw,  and  clasped  to  a  bicuspid  or  molar  on  each  side.  The  plate 
in  this  case  must  necessarily  come  close  to,  and  sometimes  even 
rest  against,  the  inside  of  the  lower  teeth.  Unless  it  fit  with 
great  accuracy  and  is  firmly  secured,  such  a  partial  lower  piece 
is  very  apt  to  cause  irritation,  disease  and  absorption  of  the 
gums  and  alveoli  over  which  it  passes. 


Fig.  242. 


INCISORS  AND  CUSPIDS  WITH  CLASPS. 

The  construction  of  the  plate  represented  in  Fig.  242  is  upon 
precisely  the  same  principle  as  the  preceding,  the  only  difference 
being  that  the  part  of  the 
plate  on  which  the  teeth 
are  mounted  fills  a  larger 
vacancy  in  the  alveoj^r 
arch.  As  in  the  former 
case,  when  the  teeth  on 
one  side  of  the  mouth  are 
too  much  decayed,  or  are 
incapable  of  affording  a 
secure  attachment,  or  are  missing,  even  this  number  of  teeth 
may  be  held  by  one  or  two  clasps  on  only  one  side  of  the  mouth; 
but  whenever  this  is  done,  the  plate  should  be  extended  half  or 
three-fourths  of  an  inch  back  of  the  tooth  to  which  it  is  clasped. 


712  BICUSPIDS    WITH    ONE   CLASP. 

If  this  precaution  is  neglected,  the  piece,  from  its  weight,  will 
act  as  a  lever  upon  the  tooth,  and  soon  loosen  it  and  cause  it  to 

drop  out. 

It  often  happens  that  pieces,  made  originally  with  clasps  on 
both  sides  of  the  mouth,  lose  the  benefit  of  one  clasp  from  the 
loi^s  of  the  tooth ;  and  yet  the  patients  retain  them  in  place,  and 
often  use  them  as  well  as  before.  The  piece  is  then,  in  part,  re- 
tained by  the  fit  of  the  plate  to  the  gum ;  in  other  words,  by 
atmospheric  pressure.  From  which  cases  we  may  learn  that  if 
only  one  clasp  can  be  attached  to  a  plate  with  from  four  to  six 
teeth,  it  will  be  advisable  to  cover  rather  more  of  the  surface  of 
the  mouth.  In  this  combination,  the  clasp  gives  steadiness,  and 
the  close  fit  of  the  plate  to  the  gum  gives  adhesion. 

BICUSPIDS  WITH  ONE  CLASP. 

The  manner  of  constructing  a  substitute  for  two  upper  bicus- 
pids on  the  same  side  of  the  mouth  is  exhibited  in  Fig.  243 ;  but 

when   the  adioininff  first  molar  does  not  offer  a 
Fig.  243.  . 

suitable  support  for  the  piece,  the  plate  may  be 

extended  backward,  and  secured  by  clasp  to  the 
second ;  if  this  also  is  diseased,  or  has  been  re- 
moved, the  plate  must  be  carried  across  to  the 
opposite  side  of  the  mouth,  and  secured  to  such 
teeth  as  may  there  offer  the  best  means  of  at- 
tachment. But  in  this,  as  in  similar  cases,  the  plate  should  be 
thick,  and  adapted  with  the  most  perfect  accuracy  to  the  parts 
against  which  it  is  to  rest.  If  the  clasp  or  clasps  are  of  the 
proper  width,  and  well  adapted,  the  teeth  will  be  held  firmly  in 
place,  and  can  be  worn  without  inconvenience. 

But  a  small  plate,  as  shown  in  Fig.  243,  does  not  afford  so 
firm  a  basis  for  mastication,  where  there  are  antagonizing  lower 
bicuspids,  as  a  larger  plate  passing  across  the  arch.  Such  a 
plate  should  be  curved  on  the  front  edge,  as  seen  in  Fig.  244, 
but  must  be  twice  or  three  times  as  wide  as  the  connecting  band 
there  shown.  Either  two  clasps  may  be  used,  or  one,  and  that 
on  whichever  side  the  most  suitable  tooth  is  situated. 


BICUSPIDS    AND    FIRST    MOLARS    WITH    CLASPS. 


713 


BICUSPIDS  AND  FIRST  MOLARS  WITH  CLASPS. 


Fig.  244. 


The  usual  plan  of  con.structing  a  plate  for  the  substitution  of 
these  teeth  is  to  cover  the  parts  of  the  alveolar  ridge  to  be  sup- 
plied with  artificial  teeth,  ex- 
tending the  plate  across  and  im- 
mediately behind  the  front  teeth,  /iifj^>.<4fe^^  ^^^^s^'^t 
and  confining  the  posterior  ex- 
tremities with  clasps  applied  to 
the  second  molars.  Fig.  251 
gives  some  idea  of  the  shape  of 
such  a  plate,  except  that  there 
should  be  no  outside  front  band, 
nor  should  the  front  of  the  plate 

run  up  with  festooned  edge  against  the  teeth.  It  is  thought,  by 
some,  that  greater  stability  may  be  given  to  the  piece  by  using 
two  separate  plates  and  connecting  them  together  by  means  of  a 
strip  of  thick  plate  passing  across  the  palatine  arch,  in  the  man- 
ner shown  in  Fig.  244.  This  method  of  connecting  two  pieces 
was  described  to  the  author  in  1844,  by  the  late  Dr.  L.  Roper. 
It  will  also  be  found  valuable  for  giving  stability  to  a  narrow  at- 
mospheric-pressure plate  (Fig.  249)  for  an  entire  upper  set  of 
teeth. 

Another  method,  stronger  than  this,  is  to  make  two  connect- 
ing-bands— one  in  front,  the  other  behind.  The  best  way  to 
make  such  a  plate  is  to  swage  in  one  piece,  and  then  cut  out  the 
centre.  The  only-  reason  why  such  pieces  are  more  steady  than 
the  solid  plate  is  because  there  is  no  bearing  upon  the  hard  cen- 
tral portion  of  the  palate  to  cause  a  rocking  or  tilting  motion. 
The  same  result  may  be  reached  by  filling  up  the  central  part 
of  the  model,  so  as  to  take  off  the  bearing  of  the  plate.  The 
latter  makes  a  stronger  plate,  and  if  the  space  is  made  a  vacuum 
cavity,  the  plate  may  adhere  at  once,  without  the  necessity  of 
clasps.  But  the  advantage  of  cutting  out  the  plate  is  the  expo- 
sure of  a  larger  surface  of  the  mucous  membrane — a  very  desi- 
rable point  with  some  patients. 


46 


714         CLASP-PLATE    WHERE    ONLY    ONE    MOLAR    REMAINS. 


INCISORS,  CUSPIDS  AND  BICUSPIDS  WITH  CLASPS. 

When  the  crowns  of  the  first  molars  of  the  upper  jaw  are  long, 
well  developed  and  in  a   healthy  condition,  the  loss  of  the  ten 
Fig.  245.  anterior    teeth    may    be    re- 

placed with  an  artificial  sub- 
stitute, such  as  is  represented 
in  Fig.  245,  that  will  sub- 
serve the  purposes  of  correct 
-/        .^^"^»\>  "^^^iw       enunciation,   as   well   as  the 

natural     organs,    and    upon 
which     mastication    may    be 
conveniently  performed.  The 
WB:'''  "»»"-'"*'        teeth  should  be  attached  to  a 

thick,  strong  plate,  and  secured  to  the  first  molars  by  broad 
clasps.  They  must,  of  course,  be  accurately  antagonized ;  for 
upon  this  will  their  utility,  in  a  great  measure,  depend.  The 
plate,  too,  should  extend  on  the  inner  side  of  the  arch  back  of 
the  teeth  to  which  it  is  clasped,  and  when  the  second  anr!  third 
molars  are  wanting,  it  may  cover  the  entire  alveolar  ridge  back 
of  the  first  molars. 

A  plate  of  this  size  and  shape  is  retained,  not  alone  by  the 
clasps,  but  also  (provided  it  is  well  fitted  to  the  gum)  by  atmos- 
pheric pressure.  In  fact,  such  a  plate  might  even  be  worn  with- 
out clasps,  after  it  has  once  become  perfectly  adapted  to  the 
mouth ;  as  we  see  often  occurring  in  consequence  of  the  loss  by 
decay  of  the  clasp-teeth. 


CLASP.PLATE  WHERE  ONLY  ONE  MOLAR  REMAINS. 

The  dentist  is  sometimes  called  on  to  replace  the  loss  of  upper 
teeth,  when  there  is  only  a  single  molar  remaining.  It  would, 
unquestionably,  be  better,  in  cases  of  this  sort,  to  remove  the 
remaining  tooth  and  apply  a  whole  upper  set  on  the  atmospheric- 
pressure  principle,  but  this  he  is  not  always  permitted  to  do. 
One,  two  or  four  teeth  remaining  at  the  back  part  of  the  mouth 
do  not  necessarily  prevent  the  use  of  an  atmospheric  plate, 
or    require   clasps.      But    a   first  molar,  with  no  teeth  behind 


LATERAL  INCISORS  AND  LEFT  BICUSPIDS  WITH  CLASPS.      715 


it,  should  be  extracted,  especially  if,  as  is  usually  the  case,  there 

is  any  considerable  absorption  of  its  socket. 

A  clasp  on  a  second  (as  in  Fig.  246)  or  third  molar  can  be  of 

little   service,  except  to  arive 

'■  .  Fig    246. 

lateral  stability  to  the  piece. 
Its  adhesion  to  the  gum  must 
be  secured  by  accurate  adapta- 
tion. This  may  be  obtained, 
even  where  the  plate  is  cut 
out,  as  in  Fig.  246.  Stiffness 
of  plate  is  best  obtained  by 
having  a  thick  plate;  but  it 
may  be  increased  by  the  use 
of  a  band,  as  in  Fig.  249. 

The  propriety  of  allowing 
teeth  to  remain,  in  such  cases, 
is  often  a  difficult  point  to  decide.  A  sound  or  well-filled  healthy 
molar  that  has  an  antagonist  ought  not  to  be  extracted  merely  be- 
cause it  would  be  easier  to  make  a  well-fitting  plate.  But  where 
the  teeih  are  diseased  or  loose,  or  the  alveolus  is  much  absorbed, 
they  ought  not  to  remain  ;  and  where  they  have  no  antagonist 
or  are  very  much  inclined,  the  propriety  of  their  retention  is 
doubtful.  One  point  should,  in  all  such  cases,  be  submitted  to 
the  patient,  namely ;  that  one  or  two  teeth  interfere  with  the 
durability  of  a  piece,  as  their  ultimate  loss  may  occasion  such 
changes  in  the  form  of  the  mouth  as  to  require  a  new  piece. 


LATERAL  INCISORS  AND  LEFT  BICUSPIDS  WITH  CLASPS. 

It  often  happens  that  there  are  several  spaces  in  the  alveolar 
ridge  which  the  dentist  is  called  upon  to  fill,  separated  by  one 
or  more  intervening  natural  teeth.  The  insertion  of  artificial 
teeth  in  cases  of  this  description  usually  requires  more  judg- 
ment and  skill  than  where  there  is  only  a  single  space.  The 
impression  is  generally  more  difficult  to  take,  and  the  plate 
will  be  much  more  troublesome  to  swage,  unless  all  the  teeth 
are  cut  down  upon  the  model  and  die.  The  nice  adaptation 
of  the  teeth  to  the  shape  of  the  gum  and  color  of  the  teeth,  so 
as  to  preserve  a  natural  appearance,  requires,  also,  the  greatest 


Tin   LATERAL  INCISORS  AND  LEFT  BICUSPIDS  WITH  CLASPS. 


care.     In  selecting  the   teeth  to  be   clasped,  the  rules   before 
(»iven  must  be  observed.     If  choice  of  position  is  allowed,  take 

second  bicuspids  or  first  molars 


Fig.  24'i 


% 


in  preference ;    never  incisors, 

canines    or    third   molars.      In 

case  of  two  clasps,  let  them  be, 

ca^^^^  %1\"  ^^  possible,  on  opposite  sides  of 

the  mouth;  but  occasionally 
they  may  both  have  to  be  on 
the  same  side,  as  in  Fig.  247, 
when  the  piece  is  of  such  size 
that  one  is  not  thought  suffi- 
cient. 

Tiie  plate  should  be  kept  clear  of  the  remaining  teeth,  and  if 
there  are  no  antagonizing  teeth  beneath,  the  molars  may  be 
omitted,  as  in  Fig.  247,  to  give  as  much  lightness  as  possible ; 
unless  their  omission  causes  a  falling  in  of  the  cheek,  in  which 
case,  two  broad  incisors  might  be  substituted  for  molars.  The 
different  forms  required  for  all  varieties  of  such  cases  are  almost 
infinite.  The  one  given  in  Fig.  247  will  serve  merely  to  show 
the  general  plan  of  construction. 

We  have  given  the  foregoing  illustrations  of  partial  clasp-sets 
of  artificial  teeth,  as  the  use  of  clasps  was  formerly  very  gene- 
ral, and  is  even  now  not  unfrequently  demanded,  either  by  the 
patient  or  by  the  nature  of  the  case.  Teeth  are  more  firmly 
retained  by  them  than  by  atmospheric  pressure,  and  this,  with 
many  patients,  outweighs  all  considerations  of  injury  to  the 
other  teeth,  &c.  The  method  of  insertion  by  atmospheric  pres- 
sure will  be  noticed  in  the  next  chapter. 


CHAPTER     FIFTEENTH. 

ARTIFICIAL  TEETH  RETAINED  BY  ATMOSPHERIC  PRES- 
SURE. 

Of  the  two  methods  of  retaining  a  dental  appliance,  already 
considered,  the  second,  by  clasps,  is  adapted  only  to  partial 
cases ;  the  first,  by  springs,  is  suited  only  to  entire  dentures. 
The  principle  of  retention  now  to  be  considered,  is  applicable  to 
either,  and  where  practicable,  is  by  far  the  most  perfect  way  of 
securing  the  adhesion  of  a  set  of  artificial  teeth.  We  shall  in 
the  next  section  treat  of  a  modification  of  this  principle  which 
comes,  however,  under  the  same  physical  law  of  "  atmospheric 
pressure,"  that  gives  to  the  method  its  name. 

Upon  this  subject  Professor  Austen  remarks — "  The  surfaces 
of  two  pieces  of  highly  polished  ground-glass  if  pressed 
together  will  adhere  firmly  ;  so  much  so,  sometimes,  as  to  resist 
every  attempt  at  separation.  Surfaces  less  smooth  and  close- 
grained  will  also  adhere  with  great  tenacity,  if  their  pores  or 
irregularities  are  filled  by  wetting  with  water. 

"If  both  surfaces  are  rigid  and  level,  they  may  be  made  to 
slide  upon  each  other,  but  will  resist  a  force  of  five  to  fifteen 
pounds,  for  every  square  inch,  if  applied  at  right  angles  to  the 
surface.  But  if  one- surface  is  soft  and  pliant,  it  becomes  diffi- 
cult to  keep  it  in  contact  around  the  edges.  Traction  upon  the  centre 
(as  in  the  case  of  a  disc  of  wet  leather  upon  a  flat-stone)  will  draw 
in  the  edges  and  create  a  vacuum  in  the  centre.  Many  suppose 
that  in  this  vacuum  space,  lies  the  power  that  raises  the  stone  : 
v/hereas,  it  lessens  the  power  by  reducing  the  area  of  stone,  in 
contact  with  the  leather.  Still  if  the  entire  circumference  is  in 
contact,  no  air  enters  the  cavity  except  what  passes  through  the 
porous  leather,  and  for  a  time  the  lifting  power  of  the  disc  is 
sufficient  to  raise  the  stone.  If  traction  be  made  upon  the  disc 
anywhere  but  in  the  centre  the  flexible  edge  will  be  raised,  air 
gets  between  the  surfaces  and  counteracts  that  pressure  on  the 
under  side  of  the  stone  which  was  the  lifting  force. 


718  TEETH    RETAINED    BY    ATMOSPHERIC    PRESSURE. 

"Hence,  between  two  surfaces,  adhering  by  simple  contact,  one 
of  which  is  soft  and  pliant,  adhesion  is  not  so  persistent  as  where 
both  are  ri^id — because  of  the  liability  to  separation  around  the 
ed^es,  admitting  air  between  the  surfaces.  Applying  this  to 
dental  plates,  we  may  understand  their  liability  to  become  de- 
tached by  a  degree  of  motion  Avhich  separates  them  from  the 
gum  at  any  one  point  around  the  edge.  We  learn  also,  that  so 
lone  as  absolute  contact  is  maintained,  we  have  the  most  perfect 
exclusion  of  air  practicable ;  hence,  no  force  of  adhesion  in  a 
limited  vacuum  cavity,  (the  perfect  exhaustion  of  which  is  im- 
possible,) is  comparable  to  the  adhesion  of  the  entire  surface  of 
the  plate — provided  this  is  made  as  perfect  as  possible  by  accu- 
rate workmanship,  and  is  not  weakened  by  the  admission  of  air 
around  the  edges. 

"  It  is  well  known  that  the  tissues  and  fluids  of  the  body 
are,  in  common  with  all  matter  at  or  near  the  level  of  the  sea, 
subject  to  a  pressure  which  is  only  felt  when  its  equilibrium  is 
disturbed.  This  pressure  measures  the  weight  cf  the  superin- 
cumbent atmosphere,  and  amounts  to  fifteen  pounds  upon  every 
square  inch  of  the  body,  pressing  alike  in  every  direction,  up- 
ward, downward  and  laterally.  If  we  exhaust  the  air  from  the 
barrel  of  a  key,  and  apply  the  lip  it  will  be  drawn  in,  and  held 
with  a  force  sufficient  to  support  the  weight  of  the  key  for  some 
time. 

''  This  simple  experiment  is  instructive,  if  we  will  only  study  its 
teachings.  The  mucous  and  submucous  tissues  are  pressed  into 
the  key,  because  the  fluids  pervading  these  parts,  being  under 
pressure  in  every  other  direction  tend  toward  the  point  from 
which  the  pressure  is  wholly  or  partially  removed.  The  extent 
to  which  the  lip  is  drawn  into  the  key  will  depend  upon  two  con- 
ditions. Firsts  the  softness  and  mobility  of  the  tissue  ;  secondly, 
the  shape  of  the  edge  of  the  orifice.  If,  in  addition  to  these  two 
points  we  inquire,  thirdly,  why  the  key,  after  a  time,  drops  off", 
we  shall  from  this  simple  illustration  have  fully  explained  the 
ratioiiak"  of  tlu'  vacuum  cavity,  as  applied  for  the  retention  of  a 
piece  of  dental  mechanism. 

-'  Fimt:  the  extent  to  which,  or  rapidity  with  which  a  partial 
vacuum  becomes  filled  up  by  any  yielding  tissue  with  which  it 
is  brought  in  contact,  depends  upon  the  mobility  of  its  structure. 


I 


TEETH    RETAINED    BY    ATMOSPHERIC    PRESSURE.  719 

(We  say,  partial  vacuum,  because  the  process  of  mechanical  ex- 
haustion can  never  produce  a  perfect  vacuum.  Theoretically, 
there  is  no  such  thing  as  an  absolute  vacuum.  That  of  contact, 
is  the  most  complete,  but  the  most  compact  substances  can  be 
proved  to  be  porous :  the  Torricellian  vacuum,  or  that  from  con- 
densed steam,  contain,  in  the  one  case,  vapor  of  water,  in  the 
other,  vapor  of  mercury.)  If  the  water  which  gives  softness 
to  the  mucous  tissues  were  perfectly  free  to  move,  the  cavity 
would  be  instantly  filled,  however  deep.  Parts  as  mobile  as  the 
tongue  and  lips,  yield  readily  to  this  fluid  pressure ;  but  the 
super-osseous  mucous  membrane,,  being  more  or  less  tied  down 
to  the  bone,  fills  the  cavity  more  slowly,  and,  if  too  deep,  will 
not  fill  it  at  all,  except  by  increase  of  substance  (hypertrophy). 

"  But  again,  reverting  to  the  experiment  of  the  key,  if  violent 
suction  is  made,  a  purple  spot  is  left  upon  the  lip,  which  is  thus 
caused — the  mucous  tissues  being  prevented  by  their  structure 
from  filling  the  vacuum,  the  fluids  still  feel  the  vis  a  tergo  of 
atmospheric  pressure.  The  most  abundant  of  these  fluids,  the 
blood,  is  thus  impelled  with  a  force  which  the  thin  capillary 
walls  cannot  resist,  and  extravasation  of  blood  is  the  result. 
This  is  also  seen  in  the  application  of  "  dry  cups."  Hence,  we 
see,  that  where  the  cavity  is  so  deep,  or  the  tissue  so  rigid  as  not 
to  fill  it,  if  the  degree  of  exhaustion  is  such,  as  still  to  draw 
upon  the  surface,  the  tissues  are  in  danger  of  being  ruptured. 
Such  a  source  of  irritation  will,  in  many  persons,  develop  a 
morbid  action,  Avhich  should  forbid  the  action  of  this  method 
of  attaching  plates. 

'•''Secondly :  the  shape  of  the  edge  modifies  the  rapidity  with 
which  the  cavity  tills.  For  instance,  under  a  cuppin.f-glass,  if 
the  edge  is  rounded,  the  skin  slides  over  it,  and  is  drawn,  with 
the  sub-cutaneous  tissue,  from  the  adjoining  parts  into  the  glass  ; 
but  if  the  edge  is  ground  so  as  to  present  a  sharp  right-angle 
on  the  inside,  this  edge  embeds  itself  in  the  surface,  and  pre- 
vents so  much  of  the  adjacent  skin  from  being  drawn  in.  It 
rises  to  a  less  height  in  the  cup,  and  the  force  of  the  vacuum  is 
then  spent  upon  the  capillary  vessels,  which  are  ruptured. 
Hence,  we  learn,  that  sharp-edged  cavities  fill  less  rapidly,  but 
act  with  more  power  upon  the  tissues,  and  are  consequently 
more  apt  to  excite  morbid  action. 


720  TEETB    RETAINED    BY    ATMOSPUERIC    PRESSURE. 

^'■Thirdly :  as  to  the  cause  of  the  final  dropping  off  of  the  kej. 
All  watiT,  and  all  the  moist  tissues  of  tlie  body,  contain  atmos- 
pheric air,  which  they  yield  up  under  a  vacuum.  Hence,  a 
mucous  membrane,  although,  at  first  drawn  strongly  into  a 
cavity,  will  make  the  vacuum  less  complete,  by  giving  out  the 
air  contained  in  its  tissue,  and  in  the  blood  constantly  circulat- 
ing through  it.  The  adhesion  of  a  vacuum,  therefore,  over 
mucous  membranes,  requires  renewal  by  occasional  suction, 
since  the  blood,  containing  air,  is  constantly  circulating  through 
the  surface,  and  supplies  air  to  the  cavity. 

"  In  this  connection,  I  would  direct  attention  to  the  property 
which  mucous  membranes  have  of  absorbing  air.  This  is  seen 
in  the  lining  of  the  bronchial  cells  constantly,  and  in  the  power 
of  the  mucous  membrane  of  the  intestines  to  absorb  the  gases 
there  generated.  This  property  acts  an  important  part,  wlien 
there  is  no  power  of  the  vacuum  to  counteract  it,  in  absorbing 
small  quantities  of  air,  unavoidably  caught  between  the  plate 
and  the  mouth.  It  explains,  in  part,  the  well  known  fact,  that 
plates  adhering  by  simple  contact,  become  tighter  after  being 
worn  awhile :  while,  in  the  last  paragraph,  the  reason  is  given 
why  plates  adhering  by  means  of  the  vacuum  cavity  are  firmest 
at  first. 

"  The  practical  inference  from  the  foregoino-  remarks,  is,  that 
the  vacuum  cavity  acts  well  at  first,  and  may  be  useful  for  the 
temporary  purpose  of  retaining  a  plate,  until  the  changes  of 
which  the  mouth  is  capable,  adapt  it  more  perfectly  to  the 
plate;  but  for  permanent  adhesion,  the  only  reliable  applica- 
tion of  the  atmospheric-pressure  principle,  is,  the  '  vacuum  of 
contact,'  to  be  found  only  in  well  fitting  plates. 

"  In  conclusion,  we  remark,  that  a  vacuum  cavity  acting  as 
such,  gradually  draws  the  gum  into  it,  and  finally  fills  it  by  a 
more  or  less  permanent  enlargement ;  (or  if  the  shape  of  the 
cavity  is  such  that  it  is  impossible  to  fill  it,  the  irritation  is  apt 
to  excite  morbid  action,)  and  that,  when  thus  filled,  the  plate  is 
then  retained,  solely,  by  the  vacuum  of  contact.  But  when  a 
cavity,  intended  to  hold  up  a  plate,  leaves  no  prominence  or 
mark  in  the  mouth,  it  unmistakably  proves  that  it  is  exerting 
no  force  ;  it  then  diminishes  the  force  of  adhesion  by  the  pres- 
ence of  air,  and    has    no    compensating    advantage,   except  in 


TEETH    RETAINED    BY    ATMOSPHERIC    PRESSURE. 


721 


removing  pressure  from  a  hard  central  ridge,  and  thus  lessening 
the  tendency  of  the  plate  to  rock." 

The  engraving,  Fig.  248,  represents  the  appearance  of  a 
dental  substitute  for  the  upper  teeth.  The  difference  between 
the  plate  applied  upon  this  principle  p,Q    348 

and  one  with  spiral  springs,  is,  that 
the  former  is  rather  wider  than  the 
latter,  covering  more  of  the  roof, 
so  as  to  give  a  larger  surface  for 
the  pressure  of  the  atmosphere. 
It  covers  the  whole  of  the  outer 
surface  of  the  alveolar  ridge,  and 
a  considerable  portion  of  the  roof 
of  the  mouth  ;  but  it  should  not  go 
as  far   back  or  run   so  high  up  as  -<iiL-£>- 

some  dentists  are  in  the  habit  of  extending  it.  If  allowed  to 
cover  those  parts  of  the  membrane,  which  cover  the  insertion  of 
the  cheek  muscles,  on  the  outside  of  the  ridge  or  the  palate 
muscles  at  the  back  of  the  mouth,  the  gums  will  be  chafed  or 
ulcerated,  the  patient  nauseated,  and  the  piece  rendered  unstable 
by  the  action  of  the  muscles.  Unless  it  be  made  to  touch  every 
portion  of  the  surface  which  it  covers,  it  will  be  constantly  liable 
to  drop. 

It  is  not  always  necessary  to  employ  a  very  wnde  plate  to 
secure  a  sufficient  amount  of 
suction  for  its  retention.  A  com- 
paratively narrow  one  may  often 
be  made  to  adhere  with  very 
great  tenacity  to  the  gums.  But 
a  plate  of  this  kind  is  more  liable 
to  be  bent,  and  lose  its  perfect 
adaptation  to  the  parts  than  a 
wide  one,  unless  made  of  thicker 
gold.  Its  liability  to  be  injured, 
however,  in  this  way,  may  be 
measurably  prevented  by  extending  a  piece  closely  fitting  the 
palatine  arch,  across  from  one  side  to  the  other,  (Fig  249,)  in 
manner  recommended  by  Dr.  Roper  for  certain  partial  cases. 
(Fig.  244.)     In  this  way,  great  stability  may  be  given  to  a  plate 


Fig.  249. 


722  TKETH    RETAINED    BY    ATMOSPHERIC    PRESSURE. 

fur  an  upper  circle  of  teeth,  without  encumbering  the  mouth 
with  a  witle  phite.  It  might  also  be  used  with  great  advantage 
in  cases  where  it  is  necessary  to  employ  spiral  springs. 

The  successful  application  of  artificial  teeth,  upon  this  prin- 
ciple, depends  upon  having  the  plate  accurately  adapted  to  the 
parts  upon  which  it  is  to  rest.  But  however  accurately  a  plate 
may  be  made  to  fit  the  model  or  metallic  die,  it  is  sometimes 
warped  in  soldering  the  teeth  to  it,  thus  destroying  its  adapta- 
tion and  causing  it  to  rock  when  placed  in  the  mouth.  When 
this  happens,  it  cannot  be  made  to  adhere  to  the  gums,  and  con- 
sequently cannot  be  worn  with  comfort.  For  the  restoration  of 
the  plate,  a  variety  of  means  have  been  proposed.  The  one 
which  the  writer  has  found  most  successful,  consists  in  binding 
it  to  the  plaster  model  with  a  fine  iron  wire  in  such  a  way  that 
it  shall  be  made  to  touch  every  part  it  covers ;  then  gradually 
heating  the  piece  to  a  cherry  red  heat  with  the  blow-pipe  flame, 
first  protecting  the  teeth  with  a  thin  layer  of  soldering-mortar.* 
Others  cut  out  from  the  lead  counter  a  space  to  admit  the  teeth, 
and  re-swage  the  plate  with  the  teeth  attached.  But  often  the 
fault  is  irremediable,  except  by  removing  the  teeth,  and  re-swag- 
ing; and  then  the  solder  remaining  on  the  plate  makes  it  more 
apt  to  warp  than  before. 

Undoubtedly  prevention  is,  in  this  case,  better  than  cure ;  es- 
pecially, as  a  proper  attention  to  certain  points  in  the  construction 
of  a  piece  of  dental  meclianism,  will  with  certainty  prevent  the 
accident.  The  points  which  have  special  reference  to  the  warping 
of  plates  are,  briefly — a  pure  plate  and  careful  annealing ;  slow 
cooling  after  the  final  annealing;  proper  investment  in  the  sold- 
ermg  mortar,  and  slow  heating  and  cooling ;  such  adjustment 
of  the  backings  that  the  plate  shall  not  be  incurably  warped,  by 
the  contraction  of  a  solid  ridge  of  solder  across  the  front  back- 
ings;  proper  jointing  of  gum  and  block  teeth. 

But  with  all  the  care  and  precaution  that  can  be  used,  it  is 
not  possible,  in  every  case,  to  secure  absolute  accuracy  of  adap- 
tation, as  the  dies  between  which  the  plates  are  swaged  are 
necessarily  more  or  less  bruised  in  the  operation.  The  yielding 
gum  permits  a  slight  deviation  from  this  course  ;  but  many  cases 

*  The  name  suggested  by  Professor  Austen  for  nil  mixtures  of  plaster  with  other 
substances  to  enable  it  to  resist  the  contracting  effect  of  heat. 


TEETH    RETAINED    BY    ATMOSPHERIC    PRESSURE.  723 

will  require  two  or  three  dies  of  zinc,  and,  of  softer  metals,  at 
least  five  or  ten.  The  inaccuracy  caused  by  metallic  shrinkage 
has  elsewhere  been  spoken  of,  and  the  proper  remedy  directed. 

In  the  application  of  a  double  set,  on  this  principle,  the  lower 
plate  should  be  as  wide  and  long  as  the  alveolar  ridge  of  the  in- 
ferior maxilla  will  admit  of  its  being  made.  Fig.  250  represents 
a   dental    substitute   attached   to   a  p^^  250 

plaster  antagonizing  model.  The 
extremities  of  the  lower  plate,  as 
may  be  perceived,  extend  up  about 
half  an  inch  on  the  coronoid  pro- 
cesses. The  lower  alveolar  ridge, 
in  the  case  for  which  these  plates 
were  constructed,  was  almost  wholly 
wanting,  and  each  side  was  covered 
with  loose  folds  of  mucous  mem- 
brane, so  irritable  as  to  prevent  the  patient  from  wearing  arti- 
ficial teeth  applied  with  springs.  She  has  worn  the  set  here 
represented  for  many  years  without  having  experienced  the 
slightest  inconvenience. 

When  the  teeth  are  put  into  the  mouth,  the  patient  may  be 
directed  to  exhaust  the  air  from  between  the  plate  (or  plates, 
when  a  double  set  is  applied)  and  gums ;  if  properly  fitted,  this 
will  at  once  cause  them  to  adhere,  though  not  at  first,  with  as 
much  tenacity  as  after  having  been  worn  a  few  days  or  weeks, 
for  the  reasons  given  by  Prof.  Austen.  But  lower  plates  and 
upper  ones  without  a  vacuum  cavity,  do  not  necessarily  require 
this  suction  efi'ort  on  the  part  of  the  patient :  it  is  sufficient,  simply, 
to  put  them  in  place  with  slight  pressure  to  force  out  the  air. 

In  replacing  the  loss  of  the  bicuspids  and  molars  of  the  upper 
jaw  with  artificial  substitutes,  mounted  upon  an  atmospheric  or 
suction  plate,  some  dentists  seek  to  give  increased  stability  to  the 
piece  by  constructing  the  plate  in  such  a  manner  that  a  narrow 
band  shall  pass  in  front  of  the  alveolar  border,  as  represented  in 
Fig.  251.  But  unless  this  is  fitted  with  great  accuracy  it  will  irritate 
the  gums  :  it  is  also  very  apt  to  be  seen  in  talking  or  laughing, 
we,  therefore,  decidedly  prefer  to  give  the  required  strength  by 
increasing  the  thickness  of  the  plate.  Where  the  second  or  third 
molars  remain  on  either  or  both  sides,  an  atmospheric-pressure  plate 


724 


THE    VACUUM    CAVITY. 


will  answer  better  than  any  other  kind.     This  principle  may  be 
combined  with   the  use  of  clasps,  as  in  Fig.  246,  or  the  plate 


Fig.  251. 


Fig.  252. 


may  be  cut  out,  so  as  to  pass  over  the  remaining  teeth  as  re- 
commended by  Dr.  Hayes,  (Fig.  252,)  or  it  maybe  carried  along 
the  inside  only  of  the  ridge. 

In  the  application  of  one  or  two  teeth  by  atmospheric  pressure, 
it  is  necessary  to  employ  a  wide  plate,  in  order  to  present  as 
much  surface  for  the  atmosphere  to  act 
upon  as  possible.  A  substitute  for  the 
two  central  incisors  mounted  upon  a  single 
plate,  to  be  applied  upon  this  principle, 
is  represented  in  Fig.  253.  Professor 
Austen's  method  is  "  to  prevent  lateral 
motion  by  a  stay  or  narrow  semi-clasp 
on  each  side,  to  cut  the  plate  as  much  as 
possible  from  around  the  intervening  teeth, 
and  to  depend  for  adhesion  upon  accurately 
fitting  the  plate  to  such  part  and  extent  of  the  mouth  as  the  varying 
circumstances  of  each  case  may  require." 


THE  VACl  IM  CAVITY. 

A  metallic  base  for  artificial  teeth  may  be  made  to  adhere  to 
the  gums  in  many  case$,with  greater  tenacity  when  first  inserted, 
by  having  it  constructed*  with  a  cavity  opening  upon  them,  than 
by  simple  adaptation,  however  accurately  the  plate  may  be  fitted. 


THE    VACUUM    CAVITY.  725 

Still,  in  the  majority  of  cases,  it  will  adhere  with  sufficient 
tenacity  for  all  useful  and  practical  purposes ;  and  if  a  plate  of 
this  kind  can  be  so  applied  as  to  secnre perfectly  the  afmospherie 
principle,  no  permanent  advantage  whatever  is  derived  from  a 
chamber  in  the  plate,  opening  upon  the  gums.  Professor  Austen's 
explanation  of  the  theory  of  adhesion  of  atmospheric-pressure 
plates,  fully  sustains  this  opinion,  which  our  practical  experience 
has  led  us  to  adopt.  Whilst,  therefore,  with  him,  we  condemn 
the  indiscriminate  use  of  "  cavity  plates"  as  practiced  of  late 
years,  and  almost  regard  its  introduction  as  a  misfortune,  yet 
we  have  found  them  very  useful  in.  certain  cases. 

The  renson  of  the  failure  of  a  simple  atmospheric-pressure  plate 
to  fit  firmly  when  first  inserted  is  (as  explained  by  Dr.  Dwinelle), 
that  when  the  plate  is  applied  and  an  effort  made  to  exhaust  the 
air  from  between  it  and  the  gums,  the  latter,  along  the  line  and 
behind  the  edge  of  the  plate,  are  drawn  down  so  as  to  meet  it, 
thus  resisting  every  effort  made  from  without  to  withdraw  the 
air  from  the  central  part  of  the  plate  ;  so  that  the  pressure  of  the 
atmosphere  is  exerted  upon  only  a  small  breadth  of  surface,  along 
the  edge  of  it,  where  the  suction  is  constantly  liable  to  be  dis- 
turbed in  biting  upon  the  teeth. 

With  the  view  of  obviating  this  difficulty,  the  idea  of  con- 
structing a  plate  with  a  cavity,  suggested  itself  to  the  writer  as 
early  as  1835.  and  was  mentioned  at  the  time  to  several  of  his 
professional  brethren.  The  construction  of  the  chamber  which 
he  then  devised  was  found  objectionable,  and  he  abandoned  its 
use ;  and  it  was  not  until  the  early  part  of  1848,  when  he  had 
an  opportunity  of  seeing  a  cavity  plate  contrived  by  Dr.  J.  A. 
Cleaveland,  that  he  was  again  induced  to  construct  a  base  of  this 
kind.  Dr.  C.  had  first  made  cavity  plates  two  or  three  years 
previously  to  this  time.  Dr.  W.  H.  Dwinelle  made  a  cavity 
plate  with  an  external  opening  and  valve  for  exhausting  the  air, 
in  the  winter  of  1845 ;  and  in  the  summer  of  1847,  or  '48,  Dr. 
Jahial  Parmly  exhibited  to  the  author  a  plate  with  a  simple  cavity 
struck  into  it  by  swaging.  Some  months  after,  he  heard,  for 
the  first  time,  of  a  cavity  plate,  contrived  and  patented  by  Mr. 
Gilbert,  of  New  Haven.  The  cavity  in  most  of  the  plates  now 
employed,  is  formed  nearly  in  the  centre,  either  far  back  on  the 
plate  or  immediately  behind  the  alveolar  ridge  ;  but  Dr.  J.  F.  B. 


726  THE    VACUUM    CAVITY. 

FlafTfT  has  recently  added  two  lateral  cavities,  wKich  are  said  to 
prevent  the  plate  from  rocking,  and  to  give  it  increased  stability. 
With  this  brief  history  of  cavity  plates,  we  shall  proceed  to  give 
a  short  description  of  the  manner  of  constructing  them  ;  begin- 
ning first  with  the  cavity-plate  and  valve  of  Dr.  Dwinelle. 

To  the  plaster  model,  a  piece  of  wax  about  an  eighth  of  an 
inch  thick  in  the  centre,  and  five-eighths  in  diameter,  but  gradually 
diminishing  toward  its  border,  is  placed  just  behind  the  alveolar 
ridge.  With  the  model  thus  prepared,  a  metallic  die  and  counter- 
die  are  obtained.  A  plate  is  then  struck  up  in  the  usual  way  ; 
then  with  a  very  small  drill  a  hole  is  made  through  the  centre  of 
the  raised  part  of  the  plate.  This  is  next  reamed  out  to  a  cone 
shape,  the  base  terminating  outward,  and  not  exceeding  half  a 
line  in  diameter.  A  piece  of  gold  wire  is  then  fitted  to  the  conical 
hole  in  the  plate,  leaving  an  extension  to  pass  up  through  the 

plate  in  the  form  of  a  stem.     It  is  next 
Fig.  254.  Fig.  255.       ,         ,    •       ,,       ,    ^,  ,  ,1 

placed  in  the  lathe  and  ground  down 

with  powdered  Scotch-stone  and  oil, 
until  it  fits  the  cone-shaped  hole  in  the 
plate  so  perfectly  as  to  render  it  com- 
pletely air-tight ;  the  base  is  then  filed  down  to  a  level  with  the 
plate.  A  very  simple  spring  is  made  of  a  single  strip  of  gold, 
with  one  end  attached  to  the  plate,  like  a  tongue  to  an  accordeon, 
making  a  hole  or  slit  in  the  end  of  it  for  the  reception  of  the 
stem  of  the  valve.  Dr.  Dwinelle  also  recommends  that  a  piece 
of  plate  be  soldered  on  the  part  of  the  chamber  pierced  by  the 
hole  to  increase  its  thickness. 

Fig.  254  represents  an  enlarged  view  of  the  valve  and  socket 
a  a  without  the  spring  ;  also  showing  the  raised  part  of  the  plate 
b  b,  in  which  the  conical  valve  a  a  is  fitted.  In  Fig.  255,  the 
valve  spring  and  plate  combined,  are  represented.  In  exhaust- 
ing the  air  from  the  cavity,  and  between  the  plate  and  gums,  the 
valve  is  depressed,  and  the  air  drawn  through  the  small  opening, 
the  closure  of  the  valve  preventing  its  return.* 

The  next  description  of  cavity  plate  which  we  propose  to  notice 
is  the  one  contrived  by  Dr.  Cleaveland,  and  the  following  is  the 
mode  of  its  construction  : 

A  metallic  die  and  counter-die  having  been  obtained,  a  plate 

*Dr.  Dwinelle  on  Cavity  Plates,  in  No.  2,  vol.  x,  Amer.  Jour,  of  Dent.  Sci. 


THE    VACUUM    CAVITY.  727 

is  .struck  up  covering  the  entire  alveolar  border  and  extending 
back  as  far  as  the  termination  of  the  hard  palate.  This  done, 
it  is  placed  in  the  mouth,  and  if  found  to  be  accurately  adapted 
to  the  parts  against  which  it  is  placed,  it  is  then  removed,  and  a 
piece  of  half  round  gold  wire  about  the  size  of  a  common  knit- 
ting needle,  soldered  to  the  lingual  side  of  the  plate,  behind  the 
alveolar  ridge,  describing  a  circle  about  three  quarters  of  an  inch 
in  diameter.  The  part  within  the  circle  is  next  cut  out  with 
punch  forceps  or  saw,  and  the  plate  then  placed  on  the  model, 
and  a  piece  of  softened  bees-wax,  about  a  tenth  or  twelfth  part  of 
an  inch  in  thickness,  having  a  circumference  one-fourth  greater 
than  the  hole  in  the  plate,  is  placed  over  the  opening,  extending 
a  short  distance  beyond  the  wire  on  every  side.  The  wax  at  the 
outside  is  brought  to  a  tliin  edge,  and  is  also  much  thinner  in  the 
centre  than  where  it  covers  the  wire  surrounding  the  opening  in 
the  plate.  A  sand-mould  of  the  model,  with  plate  and  wax  upon 
it,  is  next  taken,  and  from  this  a  metallic  die  and  counter-die  are 
obtained.  A  thin  plate  of  gold,  large  enough  to  cover  the  wax 
on  the  first  plate,  is  now  swaged  between  these  dies,  its  edge 
chamfered  off  and  then  soldered  to  its  place  on  the  plate.  It  may 
be  secured  during  soldering  either  by  iron-Avire  clamps  or  by  gold 

rivets.     A  sectional  view  of 

,     .  Fig.  256. 

the  cavity  is  represented   in 

Fig.  25G.     The  teeth  are  ad- 

justed  and    soldered    in    the 

same  manner  as  in  the  case  of 

other  plates. 

The  Cleaveland  cavity 
causes  the  plate  to  adhere  with  great  tenacity,  and  as  from  its 
shape  it  is  impossible  for  the  mucous  membrane  to  fill  it,  the 
traction  of  this  cavity  is  constant.  A  serious  objection  to  its  use 
is  the  great  irritation  it  excites  in  the  mucous  membrane  in  the 
majority  of  cases. 

The  simple  cavity  plate  employed  by  Dr.  Jahial  Parmly,  of  New 
York,  and  patented  by  Mr.  Gilbert,  of  New  Haven,  may  be  formed 
with  as  much  ease  as  the  ordinary  plate,  and  in  most  cases,  will 
answer  as  well  as  any  other.  The  process  of  forming  a  plate 
of  this  sort  is,  first,  to  place  a  piece  of  softened  wax  on  the  centre 
of  the  model.     In  the  centre  it  should  be  about  the  tenth  part  of 


'28 


THE    VACUUM    CAVITY. 


Fig.  257. 


/ 


an  iiu'li  in  thickness,  gradually  diminishing  to  the  circumference, 
and  altuut  three-fourths  of  an  inch  in  diameter.  "With  the  model 
thus  prepared,  a  metallic  die  and  counter-die  are  made,  plate 
swaged,  &c.,  in  the  manner  already  described. 

Fig.  257  represents  a  sectional  view  of  a  plate  of  this  descrip- 
tion.  If  it  is  desired  to  have 
lateral      chambers     in    the 
plate,    three  pieces   of  wax 
are   placed    on    the   plaster 
f  !j«i"*.*^    in<»del  instead  of  one.      One 
ililiiiii)'    -^='y  ^^^  placed  in  the  centre, 
as    already    described,    and 
one  on  the  slope  of  the  alveolar  ridge  on  each  side. 

When  it  is  desirable  to  make  a  cavity  with  sharply  defined 
border,  the  projection  on  the  model  should  have  a  decided  edge 
instead  of  a  gradual  slope.  A  second  plate  a  little  larger  than 
the  projection,  should  be  swaged  with  the  base-plate.  From  the 
base-plate  the  projection  is  to  be  cut  out,  and  the  smaller  plate 
soldered*  over  the  opening.  For  hard  mouths  the  thickness  of 
the  main  plate  will  give  sufficient  depth  of  cavity ;  in  this  case 
no  projection  is  to  be  placed  on  the  model. 

The  remarks  which  we  have  thus  far  made  upon  cavity  plates, 

Fig.  258. 


I 


apply  to  entire  tlcntures  for  the  upper  jaw.  But  they  are  appli- 
cable to  partial  cases  in  the  upper  jaw.  In  no  case  is  a  cavity 
to  be  placed  in  a  lower  jaw  plate.  With  a  cavity  plate,  the 
loss  of  a  single  tooth,  or  any  number  of  teeth,  may  be  replaced 


I 


THE    VACUUM    CAVITY.  729 

without  the  aid  of  chisps,  or  with  only  the  use  of  stays  or  half- 
clasps  to  steady  the  piece.  The  injurious  effects  liable  to  result 
from  the  use  of  clasps  which  have  already  been  noticed,  are  obviated 
by  applying  the  atmospheric-pressure  principle  to  partial  cases. 
So  successful  has  the  use  of  cavity  plates  been  in  the  hands  of 
the  author,  that  he  rarely  finds  it  necessary  to  employ  clasps. 

The  size  of  the  plate  which  he  employs  for  a  single  incisor,  or 
for  two  or  three  front  teeth,  is  indicated  by  the  dotted  line  on 
the  plaster  model,  as  represented  in  Fig.  258.  When  more  than 
two  or  three  teeth  are  required,  a  larger  plate  may  be  employed. 
The  size  of  the  cavity  is  also  represented  ;  but  the  artist  has  made 
it  too  large,  carrying  it  too  close  to  the  front  edge  of  the  plate. 
In  some  cases  it  may  be  better  to  run  the  plate  back  on  the  sides 
with  lateral  cavities  and  stays,  cutting  it  out  in  the  centre.     In 

Fig.   259,  such  a  plate  is  seen  with 

,      1    ,  ,       1  1  •  •  Fig-  259. 

stays  attached,  but  the  lateral  cavities 

are  not  marked. 

Prof.  Austen  dispenses  with  the 
cavity  not  only  in  full  permanent 
plates,  but  also  in  most  partial  cases. 
We  are  satisfied  that  the  vacuum  cavity 

is  too  often  used  as  a  substitute  for  accurate  workmanship.  When 
a  piece  of  dental  mechanism,  made  for  a  mouth  in  which  absorp- 
tion is  complete,  is  firm  when  first  introduced  (by  aid  of  a  cavity) 
and  afterward  loosens,  it  gives  strong  evidence  of  such  substitu- 
tion. The  cavity  becomes  filled  with  the  enlarged  membrane, 
no  longer  acts  as  a  vacuum,  and  the  imperfect  adaptation  of  the 
plate  is  revealed.  Whereas,  the  plate  without  cavity,  perhaps 
not  very  firm  at  first,  daily  improves,  provided  it  is  accurately 
adapted  and  the  mouth  undergoes  no  change.  Again,  and  lastly, 
when  a  cavity  is  used  in  a  plate  that  needs  none,  except  perhaps 
for  the  first  few  weeks,  the  adaptation  of  the  plate  alone  retains 
the  piece ;  the  cavity  ceases  to  act  as  a  vacuum  cavity,  and  the 
proof  of  this  is  seen  in  the  fact  that  it  leaves  no  mark  on  the 
membrane.  It  is  then  useless  except  to  relieve  pressure  over  the 
central  hard  parts  of  the  mouth.  Hence  the  propriety  of  Prof. 
Austen's  rule,  "  Use  the  vacuum  cavity  in  a  minority  of  cases,  and 
never  make  it  more  than  half  a  line  deep  for  soft  surfaces,  or 
one  fourth  of  a  line  for  hard  membranes." 
47 


i 


CHAPTER    SIXTEENTH. 
PORCELAIN  BLOCK  TEETH. 

The  perfection  to  which  the  manufacture  of  block  teeth  has 
now  arrived  renders  this  description  of  substitute  for  the  loss  of 
the  natural  organs  superior,  in  many  respects,  to  single  gum- 
teeth.  The  objections  that  formerly  existed  to  their  use  have, 
one  after  another,  gradually  disappeared  before  the  march  of 
improvement,  which  has  been  as  actively  and  as  successfully  at 
work  in  this  as  in  any  other  department  of  dental  art.  But 
more  time  and  more  close  and  persevering  application,  are  neces- 
sary to  obtain  a  thorough  knowledge  of  this  than  almost  any 
other  branch  of  practical  dentistry;  also,  more  constant  practice 
is  required  to  keep  the  hand  trained  to  the  requisite  skill.  The 
preparation  of  the  various  materials  which  enter  into  the  com- 
position of  block  teeth  requires  some  knowledge  of  chemistry; 
and  to  incorporate  these  materials  together  after  they  have  been 
prepared,  and  mould  them  into  a  dental  substitute,  demand  the 
nicest  and  most  skillful  manipulation.  The  slightest  error  in  the 
preparation  or  mixing  of  the  materials  will  often  give  a  result 
entirely  different  from  the  one  aimed  at ;  and  teeth  made  by  dif- 
ferent persons,  or  at  different  times  by  the  same  person,  from 
the  same  recipe,  may  differ  widely  in  appearance,  depending  on  the 
manner  in  which  they  have  been  mixed,  worked  or  fired. 

In  the  description  which  we  propose  to  give  of  the  manner  of 
making  and  mounting  block  teeth,  we  shall  begin  by  enumerating 
the  materials  that  enter  into  their  composition. 

SILICIOUS  AND  ALUMINOUS  MATERIALS. 

Porcelain  teeth  are  composed  of  two  portions;  one  is  called 
the  BODY,  and  the  other  the  enamel.  The  body  is  composed 
principally  of  feld-spar,  silex  and  kaolin;  and  the  enamel  of 
feldspar,  with  a  small  trace  of  8ilex  and  coloring  material.    Va- 


SILICIOUS    AND    ALUMINOUS    MATERIALS.  731 

rious  metallic  oxides  or  metals,  reduced  to  a  state  of  minute  di- 
vision, are  the  materials  used  for  the  purpose  of  giving  the  neces- 
sary shades  of  color. 

Feld-sjmr. — This  mineral,  commonly  called,  by  porcelain- 
workers,  spavy  occurs  in  a  crystalized  shape,  in  the  form  of 
oblique,  rhomboidal  prisms,  and  is  of  a  white,  gray,  red,  brown, 
green,  yellow  or  bluish  color.  But  the  only  kind  suited  for  use  in  the 
manufacture  of  porcelain  teeth  is  the  pure  white.  It  consists, 
according  to  Rose,  of: 

Silica, 68.50 


Alumina, 
Potash, 
Lime,   . 
Oxide  of  Iron, 


17.50 
12 
1.25 

.75 


100. 

It  is  found  near  Boston,  at  New  Bedford,  Oakham  and  West 
Springfield,  Massachusetts;  at  Ticonderoga,  New  York;  near 
Philadelphia,  Pa.;  near  Wilmington,  Del.;  near  Baltimore,  Md. ; 
and  in  various  other  places  in  the  United  States.  But  the  Wil- 
mington, Philadelphia  and  Boston  spars  are  regarded  as  the  best 
varieties  for  porcelain  block  teeth. 

Previously  to  use,  it  is  put  in  a  furnace  and  heated  nearly  to 
a  white  heat,  then  thrown  into  cold  water.  It  is  then  broken 
into  small  pieces,  freed  from  impurities,  and  ground  in  a  mortar 
or  mill  to  fine  powder,  or  until  it  will  pass  through  a  sieve  of 
No.  9  bolting  cloth.  Feld-spar  is  easily  fused,  and,  when  tho- 
roughly mixed  with  silex  and  kaolin,  its  fusion  imparts  to  the 
mass  a  semi-translucent  appearance. 

Silex. — Flint,  quartz  and  white  sand  are  the  purest  varieties 
of  silex.  For  porcelain  teeth,  the  crystaline  form  is  the  best; 
this  is  found  in  great  abundance  in  various  parts  of  the  United 
States.  It  is  prepared  for  use  by  heating  it  to  a  white  heat, 
then  plunging  it  in  cold  water,  and  afterwards  reducing  it  to  a 
fine  powder  in  a  quartz  or  wedgewood  mortar. 

Kaolin. — This  is  the  Chinese  name  for  porcelain  clay.  Beds 
of  kaolin  are  formed  in  nature  by  the  slow  decomposition  of  the 
feld-spar  of  granite  hills,  which  is  pulverized  by  the  action  of 
the  elements  and  washed  down  into  the  plains  below.     It  con- 


732  COLORING    MATERIALS. 

sists  of  nearly  equal  proportions  of  alumina  and  silica,  which  is 
the  result  of  the  decomposition  of  mineral  feld-spar,  and  is  of 
a  yellowish  or  reddish-white  color  when  pure.  It  is  found  at 
Montauk,  Vt. ;  at  Washington,  Ct. ;  at  Fairmount,  near  Phila- 
delphia: near  Wilmington,  Del.:  in  Missouri,  and  in  South 
Carolina. 

It  is  prepared  for  use  by  washing  in  clean  water.  After  the 
coarser  particles  have  settled  to  the  bottom  of  the  vessel,  the 
water  in  which  the  finer  ones  are  suspended  is  poured  off  into  a 
second  vessel,  where  it  is  permitted  to  remain  until  the  whole 
of  the  kaolin  has  settled  to  the  bottom.  The  water  is  then 
poured  off,  and  the  kaolin  dried  in  the  sun. 

There  are  other  varieties  of  clay  which  have  been  found  to 
answer  quite  as  well  as  the  porcelain.  That  which  shrinks  least 
is,  of  course,  preferable.  Two  kinds  are  found  near  Baltimore, 
which  shrink  but  very  little  in  baking;  one  is  of  a  grayish-white, 
and  the  other  of  a  bluish-white,  color.  But  less  importance  is 
attached  to  clay  as  a  constituent  of  porcelain  block  teeth,  at  this 
time  than  formerly.  Many  dispense  with  the  use  of  it  almost 
altogether. 

COLORING  MATERIALS. 
The  materials  used  for  coloring  porcelain  teeth  are,  as  we  have 
before  stated,  metals  in  a  state  of  minute  division,  or  metallic 
oxides  mixed  in  certain  proportions  with  the  body  and  enamel. 
The  following  are  the  principal  metals  and  oxides  employed  for 
purpose : 

Metals  and  Oxides  Used.  Color  Given. 

Gold  and  its  Oxides,         .         .     Bright  rose  red. 


Purple  of  Cassius,  . 
Oxide  of  Manganese, 
Oxide  of  Cobalt, 
Platina  Sponge  or  Filings, 
Oxide  of  Titanium, . 
Oxide  of  Silver, 
Oxide  of  Uranium,  . 

Of  the  above,  gold  and  its  oxides,  platina  sponge  and  oxide  of 
titanium  are  the  most  important.  With  these,  nearly  every  color 
and  tint  required  may  be  obtained. 


Rose-purple. 

Purple. 

Bright  blue. 

Grayish-blue. 

Bright  yellow. 

Lemon-yellow. 

Greenish-yellow. 


COLORING    MATERIALS.  733 

Metallic  Gold. — This  may  be  prepared  for  use  by  grinding 
gold,  in  filings  or  in  leaf,  with  a  small  quantity  of  spar  in  a 
mortar,  or  on  a  slab,  until  reduced  to  a  tine  powder;  or,  if  there 
be  any  doubt  with  regard  to  its  purity,  the  following  method 
may  be  adopted :  Melt  in  a  crucible  with  borax,  twelve  parts 
pure  silver,  four  parts  gold,  and  one  part  tin,  stirring,  while  in 
a  fused  state,  until  the  gold  and  silver  are  well  mixed.  It  may 
then  be  poured  into  an  ingot-mould,  rolled  very  thin  and  cut 
into  small  pieces,  or  granulated  by  being  poured  into  a  vessel 
containing  water  in  rapid  motion.  The  whole  mass  is  then  col- 
lected, put  into  an  evaporating-dish  and  nitric  acid  poured  on. 
When  this  has  become  completely  saturated  with  the  silver,  it  is 
poared  off  in  a  vessel  containing  water,  and  fresh  acid  added, 
and  the  action  continued  until  the  whole  of  the  silver  is  decom- 
posed or  dissolved,  which  may  be  known  by  the  colorless  appear- 
ance of  the  fumes.  The  pure  gold  remaining  at  the  bottom  of 
the  dish  is  washed  until  completely  free  from  acid.  A  simpler 
method  of  obtaining  a  fine  powder  consists  in  precipitating  a 
solution  of  chloride  of  gold  by  means  of  proto-sulphate  of  iron; 
then  washing  the  precipitate  with  dilute  muriatic  acid  to  remove 
all  trace  of  iron,  and  afterward  with  water  to  remove  the  acid. 

Oxide  of  Gold. — Dissolve  gold-foil  or  pure  gold  in  aqua  regia, 
composed  of  one  part  nitric  and  two  parts  muriatic  acid;  dilute 
the  solution  with  water  and  precipitate  the  gold  with  aqua  am- 
monia, using  the  precaution  not  to  add  more  than  is  required  (if 
excess  of  ammonia  is  added,  the  precipitate  will  be  re-dis- 
solved and  a  fulminating  compound  formed) ;  then  pour  off  the 
acid  and  wash  the  precipitate  with  warm  water  until  it  is  com- 
pletely freed  from  salt  of  ammonia;  after  which  it  may  be  dried 
over  a  gentle  fire. 

Platina  Sponge. — This  is  obtained  by  dissolving  filings  of  the 
metal  in  a  mixture  of  one  part  nitric  and  two  parts  muriatic  acid, 
diluting  the  solution  with  an  equal  quantity  of  water,  and  pre- 
cipitating the  platina  by  muriate  of  ammonia;  this  is  after- 
ward separated,  by  filtration,  in  the  form  of  a  yellow  powder, 
which,  on  being  exposed  to  a  red  heat,  will  leave  fine  platinum 
in  the  form  of  a  dark  lead-colored  spongy  mass. 

Purple  of  Oassim. — Recipe  No.  1.  This  is  a  compoinid  of 
gold  and  tin,  and,  according  to  Tlienard,  is  thus  made :  Dissolve 


734  COLORING    MATERIALS. 

the  gold  in  a  mixture  of  one  part  muriatic  and  two  parts  nitric 
acid,  diluting  the  solution  with  water,  filtering  and  diluting  again 
with  a  very  large  quantity  of  water.  Then  dissolve  the  tin  in 
aqua  regia^  composed  of  one  part  nitric  acid,  two  parts  water, 
and  to  every  pint  add  one  hundred  and  thirty  grains  of  muriate 
of  soda.  The  tin  should  be  pure  and  added  to  the  acid  in  small 
pieces,  waiting  for  each  one  to  be  dissolved  before  putting  in  an- 
other. The  operation  should  be  conducted  in  a  cool  place,  and 
very  slowly.  After  it  is  finished,  the  solution  is  filtered,  and 
about  one  hundred  times  its  volume  of  water  added.  The  so- 
lution of  gold  is  now  placed  in  a  glass  vessel,  and  that  of  the 
tin  added  to  it,  drop  by  drop,  stirring  constantly  with  a  glass 
rod,  until  the  liquid  assumes  the  color  of  port-wine.  When  the 
precipitate  has  settled  to  the  bottom  of  the  vessel,  the  liquid  is 
poured  off,  and  the  precipitate  washed  and  dried. 

Purple  of  Cassius. — Recipe  No.  2.  Dissolve  silver  coin  in  a 
mixture  of  one  part  nitric  acid  and  three  parts  water,  in  a  glass 
or  porcelain  vessel,  applying  a  gentle  heat.  Filter  the  solution, 
and  add  a  large  quantity  of  water.  Then  add  to  the  solution 
common  salt,  which  instantly  causes  a  dense  Avliite  precipitate  to 
tall;  this  is  the  chloride  of  silver,  which  must  be  thoroughly 
washed  and  dried.  Next  take  a  hessian  crucible  containing  two 
and  a  half  times  as  much  carbonate  of  potash  as  there  is  chlo- 
ride of  silver;  place  in  a  strong  fire,  and  add  the  chloride  very 
gradually.  When  melted,  remove  the  crucible,  and  reduce  the 
silver  to  a  convenient  form.  Now  take  of  pure  silver  432  grs., 
pure  gold  48  grs.,  pure  tin  36  grs.  Put  the  gold  and  silver  in  a 
crucible,  cover  well  with  borax,  and  melt ;  then  add  the  tin,  and 
pour  the  melted  mass  immediately  into  cold  water  contained  in 
a  wooden  or  porcelain  vessel,  to  granulate  it.  Collect  the  parti- 
cles, melt  and  granulate  again,  repeating  the  operation  two  or 
three  times,  so  as  to  mix  the  metals  thoroughly  together,  cover- 
ing the  metal  each  time  with  borax,  and  raising  the  heat  no 
higiior  than  is  necessary  to  melt  it,  as  the  proportion  of  tin  would 
be  lessened  by  oxidation. 

Put  the  alloy  in  a  porcelain  evaporating-dish,  and  add  nitric 
acid  to  decompose  the  silver,  hastening  the  operation  by  a  gentle 
heat.  Should  the  acid  cease  to  act  before  the  silver  is  all  dis- 
solved,— which  may  be  known  by  the  fumes  ceasing  to  rise, — it 


COLORING    MATERIALS.  735 

must  be  poured  off,  and  fresh  acid  added.  When  the  silver  is 
all  dissolved,  pour  off  the  acid,  leaving  the  precipitate  behind. 
Put  this,  which  is  the  purple  of  Cassius,  in  a  deep  glass  vessel;  fill 
it  with  water,  and  stir  with  a  glass  rod;  let  it  stand  until  the 
sediment  subsides  ;  then  pour  off  and  add  fresh  water,  repeating 
the  washing  until  the  water  is  free  from  all  metallic  taste.  The 
purple  of  Cassius  is  now  dried  in  an  evaporating-dish,  and  must 
be  kept  dry  for  use.  The  nitric  acid  poured  off  contains  the 
silver,  and  may  be  obtained  in  a  metallic  state  in  the  manner 
above  described  for  obtaining  pure  silver. 

Oxide  of  Titanium. — This  is  found  in  nature — sometimes  nearly 
pure,  and  sometimes  combined  with  oxide  of  iron.  The  princi- 
pal ores  are:  sphene,  common  and  foliated;  rutile,  iserine,  mena- 
chmiite;  and  octapedrite,  or  pyramidal  titanium  ore.  The  purest 
varieties  should  be  selected  for  use. 

Oxide  of  Urarmim. — The  prepared  article,  as  sold  by  chemists, 
contains  about  two  parts  of  the  metal,  and  three  of  the  oxide, 
in  the  form  of  a  yellow  powder.  It  is  generally  used  as  found 
in  nature. 

Oxide  of  Manganese. — This  occurs  abundantly  in  nature, 
and  is  obtained  from  chemists  in  the  form  of  a  coarse  black 
powder. 

Oxide  of  Silver. — This  is  made  by  dissolving  silver  in  nitric 
acid,  and  precipitating  the  silver  by  adding  potash  or  soda  to 
the  solution.  The  liquid  is  then  poured  off,  and  the  precipitate 
washed  with  water  and  dried. 

Oxide  of  Cobalt. — The  preparation  of  this  oxide  is  attended 
with  much  trouble ;  but  as  the  quantity  used  in  the  manufacture 
of  teeth  is  so  small,  we  do  not  deem  it  necessary  to  describe  the 
process,  especially  as  it  can  be  obtained  from  most  chemists. 
There  is  a  preparation  made  from  the  oxide,  superior  to  the  oxide 
itself  for  coloring  teeth.  It  is  called,  in  popular  language,  the 
ashes  of  cobalt,  and  is  made  by  wrapping  the  oxide  in  blue  Eng- 
lish laid  paper,  and  burning  it  in  a  closed  crucible.  This  gives 
a  more  desirable  tint  to  the  enamel  of  a  tooth  thau  the  oxide  * 
alone. 


'36  COMPOSITION   AND    PREPARATION    OF    BODY. 


COMPOSITION  AND  PREPARATION  OF  BODY. 

We  shall  give  the  proportions,  in  Troy  weight,  of  four  recipes 
for  BODY,  either  of  which,  if  properly  worked,  will  produce  good 
teeth : 


J 


No.  1 

No. 

3. 

Delaware  spar. 

12  oz. 

DelaAvare 

spar,         12  oz. 

Silex, 

2  "  5  dwts. 

Silex, 

3  " 

Kaolin, 

71    " 

•2 

Kaolin, 

18  dwts. 

Titanium, 

18  to  36  grs. 

Titanium, 

18  to  36  grs. 

No.  2 

No. 

4. 

Delaware  spar, 

12  oz. 

Delaware 

spar,         16  oz. 

Silex, 

8  "  8  dwts. 

Silex, 

3i" 

Kaolin, 

8     " 

Kaolin, 

i" 

Baltimore  clay. 

4     " 

Titanium, 

20  to  60  grs. 

Titanium, 

18  to  36  grs. 

Put  tlie  titanium  in  a  large  mortar,  and  grind  until  it  is  re- 
duced to  an  impalpable  powder;  then  add  the  silex  and  grind 
from  one  to  three  hours,  or  until  there  shall  be  no  perceptible 
grit ;  now  add  the  kaolin,  and  grind  from  thirty  minutes  to  an 
hour  and  a  half:  and,  lastly,  add  the  spar,  little  by  little,  and 
grind  from  forty  to  sixty  minutes.  All  the  ingredients  should 
not  be  ground  equally  fine,  as  the  translucency  of  the  teeth  is 
increased  by  having  some  coarser  than  the  rest. 

The  materials  may  be  ground  dry  or  in  water.  If  the  latter 
method  is  adopted,  a  sufficient  quantity  of  water  should,  from 
time  to  time,  be  added,  to  form  a  batter  of  the  consistence  of 
cream,  and  after  the  grinding  is  completed,  it  may  be  poured 
on  a  clean  slab  made  of  plaster  of  paris.  As  soon  as  the  ab- 
sorbing power  of  the  slab  reduces  the  mass  to  the  consistence  of 
stiff  dough,  it  should  be  removed,  and  after  having  been  beaten 
for  twenty  or  thirty  minutes  on  a  marble  slab,  it  must  be  put 
away  in  a  covered  jar  for  use.  When  the  ingredients  are  ground 
dry,  they  may  be  mixed,  a  small  quantity  at  a  time,  as  they  are 
needed  for  use.  Many  prefer  having  the  materials  ground  in 
this  way. 


COMPOSITION    AND    PREPARATION    OF    ENAMEL. 


737 


COMPOSITION  AND  PREPARATION  OF  ENAMEL. 

Any  of  the  following  recipes  will  produce  a  good  enamel,  and 
among  them  will  be  found  nearly  every  shade  of  color  and  tint 
required ;  others  may  be  obtained,  if  desired,  by  changing  the 
proportions  of  the  coloring  ingredients,  but  the  author  has  not 
found  it  necessary  to  do  so.  The  oxides  should  be  reduced  to  an 
impalpable  powder,  and  thoroughly  incorporated  with  the  enamel 
paste. 


Grayish  Blue  Eiiamel^ 

No.  1. 

*Boston  spar,  2  oz. 

Platina  sponge,  \  gr. 

Oxide  of  gold,  J  gr. 

No.  2. 

Boston  spar,  2  oz. 

Platina  sponge,  J  gr. 

Oxide  of  gold,  J  gr. 

No.  3. 

Boston  spar,  2  oz. 

Platina  sponge,  f  gr. 

Oxide  of  gold,  J  gr. 

No.  4. 

Spar,  2  oz. 

Flux,  24  grs. 

Platina  sponge,  J  gr. 


Yellow  Enamel, 

No.  1. 

Boston  spar,  2  oz. 

Titanium,  10  grs. 

Platina  sponge,  \  gr. 

Oxide  of  gold,  J  gr. 


No.  2. 
Boston  spar, 
Titanium, 
Platina  sponge, 
Oxide  of  gold. 


No.  3. 


Boston  spar. 
Titanium, 
Platina  sponge, 
Oxide  of  gold, 


2  oz. 
14  grs. 

igr- 


2  oz. 
16  grs. 

igr- 


No.  4. 


Spar, 
Flux, 
Titanium, 


2  oz. 
20  grs. 
10  grs. 


No  1  of  the  blue  and  No.  3  of  the  yellow,  will  produce  an 
enamel  that  will  suit  a  larger  proportion  of  the  cases  than  almost 
any  other.  The  coloring  ingredients  should  be  first  ground  very 
fine  with  five  or  six  dwts.  of  the  spar,  when  the  remainder  of  the 


*  Fuses  at  a  somewhat  lower  heat  than  the  varieties  from  other  localities. 


738 


COMPOSITION    AND    PREPARATION    OF    ENAMEL. 


spar  should  be  added  a  little  at  a  time,  and  ground  from  thirty 
to  forty  minutes.  The  composition  of  the  flux  used  in  No.  4,  is 
given  on  the  next  page. 

The  coloring  ingredients  for  the  following  recipes  arepi'epared 
by  being  ground  very  fine  with  spar. 

Platina  Coloring.  Titanium  Coloring. 

Boston  .spar,  1  oz.  Boston  spar,  1  oz. 

Platina  s])onge,    1  dwt.  12  grs.  Titanium,  7  dwts.  12  grs. 


Grayish  Blue  Enamel. 

Yelloto  Enamel. 

No.  1. 

No.  1. 

Boston  spar, 

2  oz. 

Boston  spar, 

2  oz. 

Platina  coloring, 

12  grs. 

Titanium  coloring, 

1  dwt. 

Titanium  coloring. 

2    " 

Platina  coloring. 

2  grs. 

No.  2. 

No.  2. 

Boston  spar, 

2  oz. 

Boston  spar, 

2  oz. 

Platina  coloring, 

1  dwt. 

Titanium  coloring, 

2  dwts 

Titanium  coloring, 

^  grs. 

Platina  coloring, 

21  grs. 

No.  3. 

No.  3. 

Boston  spar, 

2oz. 

Boston  spar. 

2  oz. 

Platina  coloring, 

36  grs. 

Titanium  coloring, 

3  dwts 

Titanium  coloring. 

3  grs. 

Platina  coloring, 

3  grs. 

The  foregoing  are  ground  separately  until  the  coloring  ingre- 
dients are  thoroughly  incorporated  with  the  spar.  By  grinding 
the  spar  too  fine,  the  life-like  appearance  and  beauty  of  the 
enamel  will  be  destroyed. 

Yellow  Enamel. 

No.  1. 

Boston  spar,  2  oz. 

Titanium,  16  grs. 

Platina  coloring,  8  grs. 

Gold  mixture,    2  dwts.  10  grs. 

The  manner  of  preparing  the  coloring  ingredients  for  the  pre- 
ceding recipe,  is  as  follows  : 


Grayish  Blue  Enamel. 

No.  1. 

Boston  spar. 

2  oz. 

Platina  coloring. 

2  dwts 

Gold  mixture. 

4  grs. 

COMPOSITION    AND    PREPARATION    OF    GUM    ENAMEL.  739 

Platina  Coloring. — Platina  sponge,  1  dwt.,  12  grs.  ;  Boston 
spar,  1  oz.  2|  dwts.,  mix  and  grind  very  fine. 

Gold  Mixture. — Dissolve  eight  grains  pure  gold,  in  aqua 
regia,  then  stir  in  twelve  and  a  half  dwts.  very  finely  ground 
spar.  When  nearly  dry,  form  it  into  a  ball,  and  fuse  it  on  a 
slide  in  a  furnace.  After  which,  pulverize  it  coarsely  and  keep 
for  use. 

For  the  yellow  enamel,  first  grind  the  titanium  and  platina 
sponge  very  fine,  then  add  the  gold  mixture,  which  should  also 
be  ground  fine  ;  after  which  add  the  spar  and  grind  until  the 
coloring  ingredients  are  thoroughly  incorporated  with  it.  Enamels 
made  from  any  of  the  recipes  here  given  may  be  used  on  any  of 
the  bodies. 

Gum  Enamel  is  made  with  spar  and  afrit,  colored  either  with 
metallic  gold  in  a  state  of  minute  division,  its  oxide,  or  purple 
of  Cassius.  Besides  the  coloring  ingredients,  gum  enamel  frit  is 
composed  of  a  Jliix,  made  especially  for  the  purpose,  and  spar. 
We  shall  first  describe  the  manner  of  making  the  flux. 

Flux. — Silex,  4  oz. ;  glass  of  borax,*  1  oz. ;  sal  tartar,  1  oz. ; 
mix  and  grind  to  an  inpalpable  powder ;  then  pack  it  in  the  bot- 
tom of  a  clean,  liffht-colored  crucible.  Cover  this  with  a  slab  of 
fire  clay,  previously  fitted  into  the  top,  and  lute  with  kaolin  or 
clay.  Now  place  the  crucible  in  a  strong  anthracite  fire,  free 
from  smoke,  and  let  it  remain  until  the  mass  is  completely  fused, 
which  will  require  from  an  hour  and  a  half  to  two  hours  and  a 
half,  according  to  the  strength  of  the  fire. 

When  cold,  break  the  crucible,  and  remove  every  particle  from 
the  flux,  which,  if  it  has  not  become  stained  by  coloring  matter 
in  the  crucible,  will  be  a  transparent  glass.  If  any  portion  has 
become  discolored,  this  should  be  broken  off",  and  the  remainder 
pulverized,  and  kept  dry  for  use.  Flint  glass  is  sometimes  used 
for  a  flux. 

Grum  Frit,  No.  1. — Metallic  gold  in  a  state  of  minute  divis- 
ion, or  its  oxide,  16  grs. ;  flux,  175  grs.  ;  spar,  700  grs. 

*  Glass  of  borax  is  made  by  putting  the  pure  crystals  in  a  clean  light-colored  cru- 
cible: then  place  ihe  crucible  in  a  charcoal  fire,  and  let  it  remain  until  the  borax  as- 
sumes a  transparent  glassy  appearance.  Now  pour  it  on  a  clean  marble  slab,  and 
when  cold,  pulverize  and  keep  in  a  well  stopped  bottle  to  prevent  it  from  absorbing 
the  moisture  from  the  air. 


740        COMPOSITION   AND    PREPARATION    OF    GUM    ENAMEL. 

Put  the  above  in  a  mortar,  and  grind  until  it  is  reduced  to  an 
impalpable  powder,  which  will  require  from  five  to  eight  hours 
constant  labor,  then  pack  it  in  a  light  colored  crucible  washed 
inside  with  a  thin  batter  of  very  finely  pulverixed  silex,  and  out- 
side with  kaolin  ;  now  fit  to  the  top  of  the  crucible  a  piece  of  slab 
and  lute  it  down  with  kaolin,  place  it  near  the  fire,  and  when 
dry  place  it  in  a  strong  anthracite  fire,  free  from  smoke,  where 
it  must  remain  until  it  is  fused,  which  will  require  from  an  hour 
and  a  half  to  two  hours,  then  remove  it  and  when  cold,  break  the 
crucible  and  grind  off  the  silex.  This  done,  it  may  be  broken 
and  ground  until  it  will  pass  through  a  No.  9  bolting  cloth  sieve. 

Gum  Frit,  No.  2. — Purple  of  Cassius,  8  grs. ;  flux,  175  grs.  ; 
spar,  700  grs.  Reduce  the  purple  of  Cassius,  in  a  mortar,  to 
an  impalpable  powder,  then  add  the  flux,  little  by  little,  grinding 
each  time  to  a  very  fine  powder.  Now  add  the  spar,  a  small 
quantity  at  a  time,  reducing  each  parcel  to  a  very  fine  powder, 
and  the  whole  to  the  utmost  degree  of  fineness.  To  do  this 
properly,  will  require  from  six  to  eight  hours  constant  labor,  and 
unless  the  mixing  and  levigation  are  properly  conducted,  the 
color  will  be  unsatisfactory. 

After  having  reduced  the  mass  to  the  proper  fineness,  select 
the  whitest  sand  crucible  that  can  be  obtained,  fit  a  piece  of  muf- 
fle-slide to  the  top,  as  a  cover.  Now  cover  the  internal  surface 
of  the  crucible  with  a  paste  made  from  finely  pulverized  quartz, 
putting  it  on  with  the  finger.  This  done,  pack  the  frit  into  it  in 
a  dry  state,  then  put  the  cover  on  and  lute  tight  with  kaolin. 
Put  an  external  coating  of  quartz  on  the  crucible,  then  bury  it 
in  a  strong  anthracite  fire,  and  let  it  remain  until  the  contents 
are  perfectly  fused.  The  time  required  for  this,  will  vary  accord- 
ing to  the  size  of  the  crucible  and  the  strength  of  the  fire.  When 
the  frit  is  completely  fused,  the  crucible  may  be  removed  from 
the  fire  ;  when  cold,  break  it  and  remove  every  particle  of  foreign 
matter.  Then  pulverize  until  it  will  pass  through  a  sieve  of  No. 
9  bolting  cloth. 

Gum  Enamel, 

No.  1.  No.  2. 

Frit,  No.  1,  3  dwts.  Frit,  No.  2,  3  dwt3. 

Spar,  9  to  12  dwts.  Spar,  3  to  18  dwts. 


ANTAGONIZING    MODEL    FOR    BLOCK    TEETH.  741 

The  spar  should  be  coarsely  ground,  in  order  to  give  the  gum 
a  granular  appearance,  and  the  quantity  of  frit  may  be  increased 
or  diminished  until  the  right  color  is  produced.  It  should,  there- 
fore, be  tried  on  test  pieces  of  body  before  being  applied  to  a 
practical  piece.  Frit  made  at  different  times  will  produce  differ- 
ent results.  The  gum-enamel,  No.  2,  is  designed  particularly 
for  body  No.  4,  and  tooth-enamel  No.  4,  but  may  be  used  on  any 
of  the  other  bodies,  and  with  any  of  the  other  tooth-enamels. 

Having  enumerated  the  materials  which  enter  into  the  compo- 
sition of  the  body  and  enamels,  and  described  the  manner  of  pre- 
paring and  mixing  them  for  use,  we  shall  proceed  to  notice  the 
method  of  making  and  mounting  the  teeth.  We  shall  begin  by 
describing  the  manner  of  obtaining  an  antagonizing  model  for  an 
upper  set  of  teeth,  and  of  making  the  matrix  for  moulding  the 
body  preparatory  to  carving  the  teeth. 

ANTAGONIZING  MODEL  FOR  AN  UPPER  SET  OF  BLOCK  TEETH. 

The  method  of  obtaining  an  antagonizing  model  for  block  teeth 
is  similar  to  the  one  described  in  a  preceding  chapter,  and  one 
made  for  this  purpose  will  answer  for  any  other  kind  of  dental 
substitute.  A  rim  of  wax  or  of  gutta-percha  about  half  an  inch 
thick,  is  placed  upon  the  lower  or  convex  surface  of  the  plate. 
This  is  then  adjusted  in  the  mouth,  and  the  patient  requested  to 
close  his  teeth  in  the  wax  with  sufficient  force  to  make  an  inden- 
tation in  it,  an  eighth  of  an  inch  deep.  The  piece  is  now  taken 
from  the  mouth,  and  the  plate  warmed  so  that  the  wax  may  be 
removed  without  changing  its  shape,  and  another  rim,  correspond- 
ing in  width  to  the  length  required  for  the  artificial  teeth,  fitted 
to  the  plate,  which  is  again  placed  in  the  mouth,  and  the  patient 
requested  to  close  his  teeth  gently  upon  the  wax.  If  all  do  not 
touch  the  lower  edge  of  it  at  the  same  instant,  it  should  be  trim- 
med off  until  they  do.  The  exterior  surface  of  the  wax  should 
be  also  cut  away  until  it  describes  the  proper  arch  for  the  buccal 
and  labial  surfaces  of  the  artificial  teeth,  and  restores  to  the  lips 
and  cheeks  their  natural  contour.  This  done,  the  patient  is  again 
requested  to  close  his  teeth  upon  the  edge  of  the  wax  with  just 
sufficient  force  to  leave  the  imprint  of  each  tooth. 


742  MANNER    OF    MAKING    A    MATRIX. 

Tlic  plate  is  now  taken  from  the  mouth,  laid  aside,  and  the 
wax  first  employed  is  placed  upon  a  piece  of  pasteboard  or  paper, 
with  the  side  in  which  the  teeth  were  partially  imbedded,  up- 
ward. The  exposed  portion  and  indentations  are  slightly  oiled, 
and  plaster  poured  on  it,  filling  the  impressions  made  by  the 
teeth,  extending  an  inch  and  a  half  behind  the  rim,  and  the 
whole  raised  to  a  level  of  half  an  inch  above  the  wax.  As  soon 
as  the  plaster  has  hardened,  the  edges  should  be  trimmed  off, 
and  a  crucial  groove,  or  two  or  three  conical  depressions  made 
in  the  lower  surface  behind  the  wax,  which  may  now  be  softened 
and  carefully  removed,  using  the  precaution  not  to  break  the 
ends  of  the  teeth.  This  half-model  of  the  articulator  is  placed 
upon  a  piece  of  paper  with  the  teeth  upward,  and  the  rim  of  wax 
last  used,  still  attached  to  the  plate,  is  adjusted  to  the  teeth  in 
such  a  manner  that  the  point  of  each  shall  enter  the  imprint 
made  by  the  natural  organs.  The  upper  surface  of  the  plate 
and  model  having  been  previously  oiled,  plaster  is  poured  on  for 
the  formation  of  the  other  half-model  of  the  articulator.  When 
the  plaster  has  sufiiciently  hardened,  the  two  pieces  are  sepa- 
rated, and  the  plate  and  wax  carefully  removed,  to  be  used  for 
the  formation  of  the  matrix,  in  which  to  mould  the  body  pre- 
paratory to  carving. 


MATRIX  FOR  MOULDING  THE  BODY  PREPARATORY  TO 
CARVING  THE  TEETH. 

Having  obtained  an  antagonizing  model,  the  inside  of  the 
wax  is  cut  away  until  it  presents  the  appearance  represented 
in  Fig.  2G0.  It  should  be  left  a  little  thicker  than  the  artificial 
teeth  will  be,  allowance  having  to  be  made  for  shrinkage  in  the 
baking,  and  also  for  the  removal  of  a  small  portion  in  carving, 
especially  at  the  part  corresponding  to  the  position  of  the  inci- 
sors and  cuspids.  The  plate  and  wax  are  now  returned  to  the 
upper  half  of  the  model,  and  the  exposed  surfaces  of  both  wax 
and  model  are  oiled  ;  then  a  thick  batter  of  plaster  of  paris  is 
poured  on  in  the  manner  described  for  making  the  upper  half  of 
the  antagonizing  model:  this  forms  the  matrix.  As  soon  as  the 
plaster  has  hardened  sufficiently,  the  edges  are  trimmed  to  the 
wax,  the  matrix  separated,  and  the  lower  part  of  the  antagoniz- 


I 


MANNER    OF    MAKING    A    MATRIX. 


743 


ing  model  applied.  Vertical  lines  are  now  made  across  the  wax, 
to  indicate  the  width  required  for  the  artificial  teeth.  See  Fig. 
261.     This  done,  the  antagonizing  half-model  is  removed,  the 


Fig.  260. 


Fig.  261. 


matrix  applied,  and  the  lines  in  the  wax  continued  across  the 
edge  of  it,  to  serve  as  a  guide  for  marking  the  width  of  the 
teeth  preparatory  to  carving.  See  Fig.  262.  The  two  parts  are 
again  separated,  and  the  plaster  cut  away  from  the  surface  of  the 
matrix  in  contact  with  the  wax,  forming  an  open  space  between 
it  and  the  edge  of  the  wax,  equal  to  about  one-tenth  or  twelfth 
of  the  width  of  the  wax.  The  matrix  will  now  present  the 
appearance,  when  the  tw'O  parts  are  put  together,  represented  in 
Fig.  262.     The  object  of  this  space  is  to  provide  for  the  shrink- 


FiG.   262. 


Fig.  263. 


age  in  the  length  of  the  teeth,  consequently  its  width  should 
correspond  with  the  amount  of  shrinkage  of  the  body  in  baking. 
Body  made  from  recipe  No.  1,  shrinks  a  little  more  than  that 


744  MOULDING    AND   CARVING. 

made  from  No.  2,  and  this  a  little  more  than  body  made  from 

No.  3. 

Having  proceeded  thus  fsir,  the  wax  may  be  removed,  and  a 
coat  of  varnish  applied  to  each  part  of  the  matrix.  The  appear- 
ance of  the  two  pieces  when  put  together  is  shown  in  Fig.  263. 
The  antagonizing  model  and  matrix,  as  will  be  perceived  from 
the  foregoing  description,  consist  of  but  three  pieces,  the  upper 
half  being  common  to  both.  By  this  simple  contrivance,  the 
artist  will  be  able  to  adapt  the  coronal  extremities  of  the  artificial 
teeth  to  the  opposing  natural  organs  with  accuracy,  as  he  can  at 
any  moment  remove  the  matrix-half,  and  apply  the  antagonizing 
half  of  the  model  to  his  work. 

Some  dentists  are  in  the  habit  of  first  carving  the  teeth  in 
wax,  and  making  over  it  a  matrix  consisting  of  five  pieces — one 
upper  and  one  lower,  and  three  for  the  sides  and  front.  In  this 
the  teeth  are  roughly  moulded.  But  as  they  afterward  require 
trimming,  and  it  is  quite  as  easy,  and  much  more  expeditious  to 
carve  them  from  the  porcelain  paste  in  the  first  instance,  a  skill- 
ful workman  can  carve  a  double  set,  after  having  moulded  the 
body  in  a  matrix  such  as  the  one  first  described,  in  an  hour  and 
a  half  or  two  hours. 

MOULDING  AND  CARVING. 

A  block  for  an  entire  set  of  teetb  for  the  upper  or  lower  jaw, 
shrinks  so  much  in  baking,  as  not  only  to  destroy  its  adaptation 
to  the  plate,  but  also  the  proper  relation  of  the  artificial  to  the 
natural  teeth.  This  difficulty  may  be  measurably  obviated  by 
making  three  blocks,  a  central  for  the  incisors  and  cuspids,  and 
two  lateral  for  the  bicuspids  and  molars.  Some  are  in  ihe  habit 
of  making  four,  but  with  a  good  body,  only  three  are  required. 
The  central  should  be  made  first. 

If  the  composition  for  the  body  has  been  ground  in  a  dry 
state,  as  much  as  may  be  needed  at  any  one  time  should  be  put 
m  a  mortar,  and  a  sufficient  quantity  of  clean  water  poured  on 
to  form  it  into  a  thick  batter,  stirring  it  until  thoroughly  mixed. 
It  should  then  be  poured  on  a  slab  of  plaster  of  paris,  as  before 
directed,  for  the  absorption  of  the  surplus  water,  and  afterward 
beaten  for  a  few  minutes  on  a  marble  or  porphyry  slab.     Thus 


MOULDING    AND    CARVING.  745 

prepared,  the  matrix,  after  having  been  well  oiled,  is  to  be  filled 
with  the  paste,  patting  it  Avith  the  fingers  for  a  minute  or  two, 
for  the  purpose  of  driving  out  the  confined  air. 

As  soon  as  the  water  has  evaporated  sufficiently,  the  paste 
protruding  from  the  matrix  may  be  trimmed  off,  the  lower  part 
of  the  mould  loosened,  but  still  kept  in  place,  and  the  width  of 
the  incisors  and  cuspids  marked  with  the  point  of  a  small  carving 
knife  up^p  the  body,  the  notches  across  the  edge  (Fig.  263)  of 
the  lower  part  of  the  matrix  serving  as  a  guide  for  this  part  of 
the  operation.  The  teeth,  however,  should  be  a  little  wider  than 
the  spaces  thus  indicated  on  the  matrix,  so  that  each  cuspid  will 
occupy  one-third  of  the  space  indicated  for  the  first  bicuspid, 
this  being  about  equal  to  the  amount  of  shrinkage  which  will 
take  place  in  the  front  or  central  block  in  baking. 

After  marking  the  vidth,  the  outline  of  the  labial  surfaces 
may  be  traced,  and  the  carving  commenced,  copying  nature  as 
closely  as  possible.  The  teeth  may  be  separated  by  drawing  a 
thread,  held  in  a  small  bow,  between  them.  The  antagonizing 
half  of  the  mould  may  be  applied  from  time  to  time,  to  enable 
the  artist  to  determine  the  amount  required  to  be  trimmed  from 
the  palatine  surface.  In  conducting  this  part  of  the  work,  a 
great  deal  of  tact  is  required,  as  the  slightest  touch,  or  accident, 
will  break  the  block — the  body,  in  this  state,  being  exceedingly 
tender  and  brittle.  If  it  should,  at  any  time,  become  too  dry, 
it  may  be  moistened  by  applying  a  little  water  with  the  point  of 
the  carving  knife,  or  a  small  camel's-hair  pencil.  The  portion 
back  of  the  cuspid  teeth  is,  of  course,  to  be  cut  off. 

Having  completed  the  front  block,  it  should  be  loosened  from 
the  plate,  by  gently  tapping  the  part  of  the  matrix  to  which  it 
is  attached,  and  then  removed  and  placed  upon  coarsely  pulver- 
ized silex,  on  a  muffie-slide.  This  done,  the  matrix  is  to  be  refilled 
with  paste,  and  the  side  blocks  carved,  making  the  first  bicuspids 
to  occupy  about  one-third  of  the  spaces  marked  on  the  matrix 
for  the  cuspids.  These  side-blocks,  when  finished  in  like  manner, 
are  removed  and  placed  with  the  central  block  on  the  slide. 

The   only  instruments  required  for  carving   are  two  or  three 
small  knives,  shaped  something  like  the  blade  of  a  thumb  lancet,  but 
more  pointed  and  smaller,  with  a  handle  made  as  light  and  deli- 
cate as  possible. 
48 


746 


CRUCING,    OR    BISCUITING. 


Fig.   2G4. 


CRUCING,  OR  BISCUITING. 

As  soon  as  the  blocks  have  become  thoroughly  dry,  the  slide  con- 
taining them  must  be  put  in  the  muffle  of  a  furnace,  previously  raised 
to  a  bright  red  heat,  sufficient  to  agglutinate  the  particles  of  the 
composition,  but  not  to  vitrify  the  body.  This  is  called  crucing  or 
biscuiting,  and  is  sometimes  done  in  a  charcoal  fire,  in  a  .^lall  open 
furnace,  the  blocks,  in  this  case,  being  placed  on  some  pulverized 
silex,  in  a  crucible.  But  it  is  most  readily  effected  in  a  muffle 
furnace. 

If  the  carving  has  been  roughly  executed,  the  shape  of  the 
teeth  may  be  to  some  slight  extent  altered,  and  any  rough  places 
removed  after  the  blocks  have  been  cooled.  They  can  now  be 
handled  without  incurring  much  risk  of  breaking. 

Several  methods  of  attaching  blocks  to  a  plate  have  been 
adopted,  but  the  one  which  gives  to  the  work  the  greatest  per- 
manence and  stability,  consists  in 
soldering  a  band  to  platina  pins  in- 
serted in  the  blocks  behind  the  teeth. 
These  pins  are  sometimes  inserted 
before  the  blocks  are  cruced,  but  as 
the  teeth  are  so  exceedingly  frail  at 
this  time,  it  is  better  to  defer  it 
until  they  have  been  subjected  to 
this  process.  The  manner  of  insert- 
ing them  is  very  simple,  and  consists  in  drilling  two  small  holes 
in  the  block  behind  each  tooth,  immersing  the  block  suddenly 
in  water,  and  inserting  a  pin  flattened  at  the  end,  in  each  hole. 
The  space  around  them  should  be  filled  with  "body"  mixed  with 
water  to  about  the  consistence  of  thin  cream.  This  may  be  ap- 
plied with  a  small  canud's-liair  pencil,  or  with  the  point  of  the 
carving-knife.  The  pins  should  pass  from  half  to  two-thirds  of 
the  way  through  the  block,  and  be  about  an  eighth  of  an  inch 
apart,  one  placed  above  the  other.  A  set  of  blocks  for  the  upper 
jaw  with  pins  inserted  are  represented  in  Fig.  264. 


FIRING    AND    BAKING.  747 


ENAMELING. 


The  enamels,  when  applied,  should  be  of  the  consistence  of 
cream,  and  if  the  teeth  are  to  have  a  uniform  color,  it  will  only 
be  necessary  to  use  two  kinds,  one  for  the  teeth  and  one  for  the 
gum.  But  in  the  majority  of  cases  three  kinds  are  needed,  a 
grayish  blue  for  the  lower  part  of  the  crown,  yellowish  near  the 
gum,  and  rose  red  for  the  gum.  The  teeth  should  be  well 
cleaned  before  the  enamel  is  put  on.  The  gum-color  should  be 
applied  first,  then  the  yellow,  and'  lastly  the  grayish  blue,  and 
the  best  method  of  putting  it  on  is  with  a  small  camel's-hair 
brush.  It  should  be  of  uniform  thickness  and  come  down  a  little 
below  the  ends  of  the  incisors  and  cuspids,  so  as  to  give  them 
the  translucency  peculiar  to  the  natural  teeth.  A  thin  coating 
may  also  be  applied  to  the  grinding  surfaces  of  the  molars  and 
bicuspids.  It  is  not  required  on  the  palatine  surfaces.  In  ap- 
plying the  gum-color,  care  should  be  taken  to  prevent  it  from 
coming  down  on  the  teeth,  and  at  the  same  time  to  have  it  form 
a  well  defined  edge.  The  grayish  blue  should  overlap  the  yel- 
low, blending  the  two  tints  in  such  a  manner  as  to  render  it 
impossible  to  tell  where  the  one  begins  or  the  other  terminates. 

The  enamels  having  been  applied,  the  blocks  are  carefully 
placed  on  a  bed  of  silex  on  the  slide,  and  when  perfectly  dry, 
slid  into  the  muffle  of  the  furnace. 

FIRING  AND  BAKING. 

This  may  be  done  in  a  small  muffle  furnace,  like  the  one  repre- 
sented in  Fig.  265 ;  some  dentists  have  a  furnace  constructed 
differently,  but  the  principle  and  general  plan  is  the  same. 
A  clear,  strong  fire,  made  of,  the  hardest  anthracite  coal,  is 
required  for  baking  the  blocks.  It  is  first  kindled  with  charcoal, 
and,  after  this  has  become  thoroughly  ignited,  the  anthracite  is 
added,  a  little  at  a  time,  until  the  furnace  is  full.  As  the  muffle, 
at  the  high  temperature  required  for  fusing  the  blocks,  and  under 
the  weio;ht  of  the  coal  above,  is  liable  to  sink  down  in  the  centre, 
it  should  be  supported  by  a  rest  underneath,  made  of  fire-clay. 
The  anthracite  coal,  after  it  has  settled  and  become  thoroughly 


748 


FIRING    AND    BAKING. 


ignited,  should  be  two  or  three  inches  deep  on  the  top  of  the 
muffle,  and  tlie  opening  through  which  the  fuel  is  introduced, 
closed. 

Fig.  265. 


Fio.  26,').  A  muffle  furnace ;  a  Collar  for  the  smoke-pipe  ;  6  The  opening  through  which  the 
fuel  is  introduced;  c  The  muffle  opening;  i  The  ash-pit  door;  c  Stopper  for  the  opening^.-/ 
Stopper  for  closing  the  opening  to  the  muffle  ;  g  Stopper  for  the  opening  to  the  ash-pit ;  h  muffle  ; 
i  Stopper  with  platina  wire  and  test ; ,/  Muffle-slide. 

The  furnace  being  thus  heated,  the  slide  (ji")  may  be  carefully 
introduced  into  the  muffle  {h)  of  the  furnace,  the  opening  closed, 
and  the  door  (/)  luted  with  fire-clay.  Some  dentists  use  a  test 
piece,  consisting  of  a  small  biscuited  piece  of  the  "body,"  with 
a  little  of  the  tooth  and  gum  enamels  on  one  side  of  it,  fixed  to 
the  end  of  a  platina  wire,  projecting  from  the  inner  extremity 
of  a  plug  made  of  fire-clay  (/),  and  fitting  a  hole  in  the  centre 
of  the  door  of  the  muffle.  By  withdrawing  this,  the  progress 
of  the  baking  can  be  ascertained :  but  the  use  of  it  is  not  ne- 
cessary, to  an  experienced  workman  in  constant  practice.  Most 
persons  are  in  the  habit  of  opening  the  door  of  the  muffle,  and 
partially  withdrawing  the  slide,  when  it  is  thought  the  blocks 
have  been  baked  sufficiently.  When  the  enamel  has  become 
fused,  and  smoothly  spread  over  the  surfaces  to  which  it  was  ap- 
plied, the  process  has  been  carried  far  enough.  The  stopper  of 
the  fuel-opening  may  now  be  removed,  the  draft  of  air  cut  off  from 


FITTING    AND    ATTACHING    BLOCKS    TO    THE    PLATE.  749 

the  fire  by  closing  the  door  to  the  ash-pit,  and  the  furnace  per- 
mitted to  cool.  When  the  combustion  has  ceased,  and  the 
temperature  has  become  so  much  reduced  as  to  permit  the 
introduction  of  the  hand  into  the  muffle,  the  slide  may  be  re- 
moved. If  it  is  taken  out  before  the  furnace  has  cooled,  the 
teeth  will  not  be  well  annealed  and  will  be  very  liable  to  crack 
under  the  blow-pipe. 

FITTING  AND  ATTACHING  THE  BLOCKS  TO  THE  PLATE. 

The  adaptation  of  the  blocks  to  the  base  is,  more  or  less,  im- 
paired by  the  shrinkage  which  takes  place  in  baking,  and  as  it 
is  important  that  they  should  fit  with  the  nicest  accuracy,  it  fre- 
quently becomes  necessary  to  grind  them  before  attaching  them 
to  the  plate.  The  blocks  should  also  be  fitted  to  each  other  so 
perfectly,  by  grinding,  as  to  render  the  line  of  union  scarcely 
perceptible,  taking  the  precaution  to  insert  the  thin  slip  of  paper 
elsewhere  spoken  of.  Very  small  Avhecls  are  required  in  the 
latter  part  of  the  grinding  process.  Where  the  eye  will  not 
reach,  accuracy  of  fit  may  be  obtained  by  coating  the  plate  with 
oil  colored  with  lamp-black  or  vermillion  :  the  spots  on  the  base 
of  the  block  which  touch  the  plate  will  be  colored.  These  are 
to  be  ground  until  the  entire  surface  becomes  spotted  over,  show- 
ing a  very  general  contact  with  the  plate. 

Having  accomplished  this  part  of  the  operation,  and  antago- 
nized the  blocks  properly  with  the  opposing  teeth,  they  are  re- 
tained in  place  with  a  rim  of  wax,  applied  to  their  outer  surface, 
where  they  join  the  plate ;  the  plate  behind  the  blocks  is  then 
oiled,  and  plaster  poured  on,  filling  the  arch,  and  covering  the 
coronal  extremities  of  the  teeth.  When  this  has  hardened,  the 
wax  on  the  outside  may  be  removed  :  the  blocks  can  now  be 
taken  from  and  applied  to  the  base  without  disturbing  their  pro- 
per relationship.  A  strip  of  gold  is  then  cut  a  little  thinner 
than  that  used  for  the  base-plate,  about  an  eighth  of  an  inch 
wide,  and  loncp  enough  to  extend  around  the  outside  of  the  entire 
arch  of  the  blocks.  This  should  be  slightly  grooved,  and  accu- 
rately fitted  to  the  plate  along  the  outer  edge  of  the  blocks, 
with  the  grooved  side  toward  them  ;  the  plate  then  marked  with  a 
sharp  pointed  steel  instrument,  on  the  outside  of  this  rim.     The 


750         FITTING    AND    ATTACHING    BLOCKS    TO    THE    PLATE. 

plaster  and  blocks  must  now  be  removed,  and  the  strip  of  gold  held 
in  its  place  by  wrapping  the  plate  with  fine  iron  wire.  It  is  then 
soldered  at  three  or  four  different  points,  and  afterward  all  the 
way  around  to  the  plate. 

This  outside  band  is  sometimes  swaged  up  or  soldered  on  be- 
fore grinding  the  blocks ;  in  which  case  the  blocks  must  be  fitted 
accurately  to  it.  A  dexterous  workman  can  rapidly  fit  a  straight 
band  to  an  irregularly  curved  outline  by  the  operation  of  "  peen- 
ing  or  paning."  The  strip  is  first  "  tacked  "  with  solder  to  the 
front  edge  of  the  plate,  and  then  with  pliers  bent  to  fit  its  curva- 
ture :  any  lateral  curves  required  in  the  strip  are  given  by  strik- 
ing it  on  a  small  anvil  with  the  "  pane  "  of  a  small  hammer,  the 
strip  curving /row  the  side  on  which  the  blow  is  struck  :  the  pane 
being  held  at  right  angles  to  the  stiip.  Others  take  an  impres- 
sion of  the  surfaces  of  blocks  and  plate  which  the  band  is  to  fit 
and  swage  the  band.  This  is  more  troublesome,  but  gives  an 
accurately  fitting  band. 

The  blocks  should  now  be  separated  from  the  plaster,  adjusted 
to  the  plate,  and  held  in  place  partly  by  the  rim  just  soldered 
to  it,  and  partly  by  a  rim  of  wax  placed  on  the  inside.  The 
next  thing  to  be  done,  is  to  apply  a  strip  of  gold  from  a  quarter 
to  three-eighths  of  an  inch  in  width,  and  of  the  thickness  of  the 
plate,  to  the  lingual  surface  of  each  block.  A  pattern  for  each 
of  these  linings  is  first  made  by  applying  sheet  lead  or  tin  to  the 
block,  which  as  it  is  pressed  against  it,  is  perforated  by  the 
platina  pins.  It  is  then  trimmed  to  the  proper  size,  and  fitted 
accurately  to  the  base.  This  is  placed  upon  gold  plate,  and  a 
piece  of  the  same  size  and  shape  cut  from  it.  The  perforations 
in  the  pattern  indicate  the  points  at  which  the  holes  are  to  be 
punciied  through  the  linings ;  this  done,  it  is  applied  and  fitted 
tightly  to  the  block,  and  held  firmly  in  place  by  bending  the 
platina  pins.  The  pins  are  then  filed  off  nearly  up  to  the 
plate,  and  the  block  returned  to  its  place.  The  lining  should 
be  made  to  fit  the  plate  and  the  end  of  the  lining  of  the  adjoin- 
mg  block  Avitli  the  most  perfect  accuracy.  If  the  inner  curve  of 
the  block  is  considerable,  or  the  pins  close  together  or  long,  it 
will  be  found  very  diflBcult  to  fit  the  lining.  For  this  reason 
some  prefer  to  put  small  separate  linings  opposite  each  tooth. 
The  finish  is  thought  to  be  not  quite  so  neat  as  the  continuous 


FITTING    AND    ATTACHING    BLOCKS    TO    THE    PLATE.  751 

lining:  but  it  is  claimed  that  the  risk  of  breaking  the  blocks  in 
backing  and  soldering  is  much  less. 

All  the  linings  having  been  applied  and  the  blocks  adjusted 
to  the  base,  the  teeth  are  held  in  place  by  a  rim  of  wax  on  the 
inside,  and  the  piece  put  in  the  soldering  mortar,  and  otherwise 
prepared  for  the  process  of  soldering  according  to  the  directions 
before  given.  Cautious  heating  up  and  very  gradual  cooling  is 
especially  necessary  in  the  case  of  blocks,  to  prevent  them  from 
cracking.  The  process  of  finishing  is  the  same  as  that  for  a  set 
of  single  teeth  mounted  upon  plate. 


Fig.  266 


Figs.  266  and  267  represent  a  front  and  palatine  view  of  an 
upper  set  of  block  teeth  mounted  on  a  metallic  base.  The  rim 
on  the  outside  around  the  upper  edge  of  the  block  is  not  always 
put  on,  but  it  adds  to  the  strength  and  beauty  of  the  piece,  and 
also  to  its  cleanliness,  if  closely  fitted,  as  it  always  should  be,  to 
the  blocks. 

There  are  two  other  methods  of  attaching  blocks  to  a  plate. 
The  first  consists  in  making  vertical  holes  through  the  blocks, 
one  for  each  tooth,  after  they  have  been  cruced.  They  are  at- 
tached to  the  plate  by  a  gold  pin,  which  is  either  passed  through 
each  tooth  and  riveted  on  the  upper  side  of  the  plate,  or  is  first 
soldered  to  the  plate,  and  then  riveted  on  the  grinding  surfaces 
of  the  molars  and  bicuspids  and  the  palatine  surfaces  of  the  in- 
cisors and  cuspids.  The  second  method  consists  in  soldering 
pins  to  the  plate  which  pass  into  holes  made  to  run  parallel  to 
each  other,  half  or  two-thirds  of  the  way  through  the  teeth,  one 

*  The  originals  of  nearly  all  the  illustrations  in  the  foregoing  chapter  were  made 
for  the  author  by  the  late  Dr.  Mortimer  D.  French,  of  Tomnto,  Canada,  formerly  a 
student  of  his.  For  a  number  of  the  receipes  tlie  author  is  indebted  to  the  courtesy  of 
several  professional  friends,  having  large  experience  in  this  dcpartuient  of  dental 
art. 


7;")2         FITTING    AND    ATTACHING    BLOCKS    TO    THE    PLATE. 

to  each  tooth.  The  pins  in  this  second  method  are  hehi  in  two 
wavs.  First  by  a  bushing  of  wood :  in  which  case  the  holes  in 
each  block  must  be  perfectly  parallel  and  smoothly  drilled,  and 
the  pins  placed  with  greatest  accuracy.  (The  method  of  plac- 
ing the  pins  is  the  same  as  that  given  in  page  622  for  a  pivot 
tooth  pin.)  But  in  the  second  way  the  holes  may  be  larger,  rough 
an<l  irregular,  and  loss  accuracy  is  required  in  locating  the  pins. 
They  are  held  in  the  block,  and  all  spaces  between  block  and 
plate  filled,  by  some  plastic  material  which  has  the  property  of 
hardening.  This  may  be  gutta  percha.  Hill's  stopping,  osteo- 
plastic, sulphur,  or,  best  of  all,  vulcanized  rubber. 

Of  these  different  methods  the  first,  by  soldering,  is  undoubt- 
edly the  strongest.  Next  in  point  of  strength  is  that  by  pins, 
if  secured  by  vulcanite.  The  most  objectionable  method  is  that 
of  the  riveted  pins.  The  pins  bushed  with  wood  make  a  very 
secure  fastening,  but  require  a  nicety  of  workmanship  which 
very  few  are  equal  to. 

In  making  blocks  for  either  a  partial  upper  case  or  for  a 
double  set  of  teeth,  the  process  above  given  may  very  readily 
be  modified  by  reference  to  the  directions  given  in  previous 
chapters  for  those  forms  of  dental  substitutes.  It  is  unneces- 
sary therefore  to  give  any  further  description  of  the  application 
of  blocks  to  such  cases. 

The  directions  given  in  the  foregoing  chapters  have  reference 
mainly  to  the  setting  of  teeth  upon  gold  plate  ;  since  a  full  know- 
ledge of  the  working  of  this  best  of  all  materials  is  absolutely 
essential  to  the  dentist.  But  many  of  these  processes  are  re- 
quired in  the  methods  of  mounting  artificial  teeth  which  form 
the  subjects  of  the  three  following  chapters.  In  the  description 
of  tliese  processes,  we  shall  therefore  not  repeat  directions  already 
given,  but  confine  our  description  to  the  steps  peculiar  to  these 
methods  respectively. 


CHAPTER    SEVENTEENTH. 

TEETH  SET  UPON  PLATINA  WITH  A  CONTINUOUS 
ARTIFICIAL  GUM. 

The  idea  of  uniting  porcelain  teeth  to  a  metallic  base  by  means 
of  a  fusible  silicious  composition,  originated  in  France,  where 
the  method  has,  to  some  extent,  been  practiced  since  1820. 
But  Dr.  Fitch,  who  spent  much  time  in  Paris,  and  was  well  ac- 
quainted with  the  French  method  and  Delabarre's  formulae, 
states,  that  the  latter  had  never  perfected  his  recipes,  or  brought 
them  into  practical  use.  The  composition  employed  there,  judg- 
ing from  the  specimens  Avhich  the  author  has  in  his  possession, 
cannot  be  used  in  connection  with  porcelain  teeth  containing  as 
large  a  proportion  of  feld-spar  as  those  manufactured  in  this 
country.  Delabarre's  compound,  according  to  Dv.  Locke,  re- 
quired 3761°  Fahrenheit,  to  fuse  it  completely.  Below  this,  it 
fused  imperfectly  and  was  found  too  fragile. 

The  process  now  known  as  the  Continuous  Gum  consists  es- 
sentially of  a  silicious  paste,  similar  (except  more  fusible)  in 
composition  to  that  of  which  the  teeth  are  made,  which  is  ap- 
plied around  the  bases  and  fastenings  of  teeth  previously  soldered 
upon  a  plate  of  purest  platina,  and  then  fused  at  a  temperature 
of  about  2200°  Fahrenheit.  It  takes  its  name  from  the  fact  that, 
unlike  blocks  or  single  gum  teeth,  it  presents  an  unbroken  con- 
tinuous gum,  outside  the  alveolar  ridge  as  is  shown  in  Fig.  268. 
It  is  applied  in  two  layers — a  yellow-  Fig.  268. 

ish  white    body,    gwmg    the ,  general 
contour  of  the    gum,  and  an    enamel 
to   produce    that   correct    imitation  of 
the  natural   gum,   for   which    nothing 
but  ceramic  materials  have  as  yet  been  X   f  f   y^l 
found  suitable.     Dr.  Allen  covers  with        •<A..,-^..j>^><-><->'^ 
the  same   material,  the  entire  lingual  surface  of  the  plate  and 
also   certain  projections  outside  of  the  molars,  and  above  the 


754  TEETH    WITH    ARTIFICIAL    CONTINUOUS    GUM. 

cuspids  designed  by  liim  for  the  restoration  of  tlie  natural  full- 
ness of  the  face. 

This  falling  in  of  the  features  is  due  to  the  absorption  of  the 
alveolar  ridge,  and  cannot  be  fully  restored  by  an  artificial  set 
of  teeth,  as  usually  made,  for  the  reason — that  if  the  molars 
were  set  out  to  the  original  width  of  the  teeth,  the  force  of 
mastication  would  fall  outside  the  absorbed  alveolus  and  render 
it  practically  useless.  Dr.  Allen's  device  corrects  this  sinking 
under  the  malar  prominence  of  the  superior  maxilla,  and  in  the 
canine  fossa,  and  thus  greatly  aids  in  the  restoration  of  the  face 
to  its  original  appearance. 

This  process  was  patented  to  Dr.  John  Allen,  in  1851  ;  but 
tlie  priority  of  invention  was  contested  hj  Dr.  Wm.  H.  Hunter, 
in  a  suit,  the  progress  and  result  of  which  are  well  known  to  all 
readers  of  the  journals.  Dr.  Allen  surrendered  his  patents  of 
1851,  owing  to  certain  defects  in  the  same,  and  in  1856,  a  new 
patent  was  issued  to  him,  for  the  process  as  then  improved. 
This  patent  also  is,  we  understand,  involved  in  litigation. 

The  process  is  very  generally  known,  as  "Allen's  Continuous 
Gum,"  the  materials  for  which,  as  prepared  by  him,  can  be  ob- 
tained at  all  the  depots.  The  formulae  given  in  this  chapter,  are 
those  of  Dr.  Hunter,  and  the  earlier  ones  of  Dr.  Allen.  As  all 
such  materials  are  more  perfectly  prepared  on  a  large  scale,  we 
think  it  much  better  to  purchase  than  to  make  them. 

A  "continuous  gum"  piece,  made  in  the  most  perfect  manner, 
is  only  surpassed  in  point  of  beauty,  by  the  occasional  produc- 
tions of  a  very  few  block-carvers ;  but  so  rare  are  these  specimens 
of  perfection  in  block-work,  that  we  may  safely  say,  of  the 
continuous  gum  work,  that,  when  properly  made,  it  is  the  most 
beautiful,  as  it  certainly  is  the  purest  and  sweetest,  that  can  be 
worn  in  the  mouth,  so  long  as  the  porcelain  covering  maintains 
its  integrity. 

As  regards  this  important  point — durability,  our  own  experi- 
ence does  not  permit  us  to  speak  confidently.  It  was  thought 
when  this  method  of  mounting  artificial  teeth  was  first  adopted, 
that  the  springing  of  the  plate  in  the  act  of  mastication  would 
cause  the  gum  to  crack  and  scale  off";  which  did  occur  in  a  large 
proportion  of  the  cases.  Although  the  injury  could  be  repaired 
by  replacing  the  loss  with  fresh  composition  and  fusing  it  to  the 


TEETH    WITH    ARTIFICIAL    CONTINUOUS    GUM.  755 

fractured  edges  of  the  remaining  portions,  and  to  the  plate, 
yet  this  formed  a  very  serious  objection  to  its  use.  But  later  im- 
provements in  the  strength  of  the  compound,  and  also  in  the 
rigidity  of  the  plate  and  soldered  backings,  have  so  far  corrected 
this  evil,  that  it  is,  perhaps,  no  more  liable  to  accident  while  in 
the  mouth  than  any  other  kind  of  work.  But,  out  of  the  mouth, 
its  weight  renders  it  peculiarly  exposed  to  accident,  and  a  fall  is 
almost  certain  to  break  one  or  more  teeth,  or  crack  the  si- 
licious  covering  of  the  plate.  Hence,  it  is  necessary  to  impress 
upon  the  patient  the  great  importance  of  the  most  careful 
handling. 

By  uniting  the  teeth  to  each  other,  near  their  base,  and  to 
the  plate  by  a  glazed  porcelanic  material,  the  cleanliness  of  the 
substitute  is  most  perfectly  secured,  as  all  the  openings  beneath 
and  around  them  are  completely  closed,  excluding  the  secretions 
of  the  mouth  and  particles  of  alimentary  substances,  which  have 
not  the  smallest  affinity  for  the  porcelain.  In  this  respect,  they 
are  superior  to  the  most  perfectly  mounted  block  teeth ;  and  the 
labor  of  putting  up  a  set  of  the  former  can  be  performed  in  half 
the  time  required  for  making  and  mounting  a  set  of  the  latter. 
A  person  who  can  mount  single  teeth  well,  may  acquire  a  knowl- 
edge of  this  method,  with  proper  instruction,  in  a  few  weeks: 
for,  although  much  of  the  peculiar  talent,  required  in  block  carv- 
ing, is  needed  in  arranging  the  teeth  and  shaping  the  gum  for 
this  process,  yet  the  details  are  comparatively  simple  and  may 
soon  be  taught.  Of  course,  much  practice  will  be  required,  es- 
pecially in  the  management  of  the  furnace  heats. 

The  artificial  gum  consists,  as  we  have  stated,  of  two  parts  ; 
the  first  is  termed  the  base  or  body,  as  this  constitutes  the 
principal  part  of  the  cement,  and  is  used  for  filling  in  between 
the  teeth  and  building  up  the  gum  on  the  plate ;  the  other  is 
gum-enamel.  The  material^  employed  by  Dr.  Hunter,  in  the 
composition  of  his  compounds  are,  silex,  fused  spar,  calcined 
borax,  caustic  potash  and  asbestos.  The  silex  and  spar  should 
be  of  the  clearest  and  best  quality,  and  ground  very  fine.  The 
asbestos  should  be  freed  from  talc  and  other  foreign  substances, 
and  reduced  to  a  fine  powder.  He  gives  the  following  formulae 
and  directions. 

Flux. — Take  of  silex,  8  oz.;   calcined  borax,  4  oz.;   caustic 


7o6  TEETH    WITH    ARTIFICIAL    CONTINUOUS    GUM. 

potash,  1  oz..  The  potash  is  first  ground  fine  in  a  wedgewood 
mortar,  and  the  other  materials  gradually  added  until  they  are 
thoroughly  mixed.  Line  a  hessian  crucible  (as  white  as  can  be 
had)  with  pure  kaolin,  fill  with  the  mass,  and  lute  on  a  cover  of 
a  piece  of  fire-clay  .slab,  with  the  same.  Expose  to  a  clear  strong 
fire  in  a  furnace  with  coke  fuel,  for  about  half  an  hour,  or  until 
it  is  fused  into  a  transparent  glass,  which  should  be  clear  and 
free  from  stain  of  any  kind.  This  is  broken  and  ground  until 
it  will  pass  a  bolting  sieve. 

Granulated  Body. — Spar,  3  oz.;  silex,  1|  oz.;  kaolin,  J  oz.; 
completely  fused.  Break  and  grind  so  that  it  will  pass  through 
a  wire  sieve  No.  50,  and  again  sift  off"  the  fine  particles  which 
pass  through  No.  10  bolting  cloth,  which  leaves  it  in  grains  about 
the  size  of  the  finest  gunpowder.  It  may  be  made  of  hard 
porcelain,  fine  china  or  wedgewood. 

Body. — Take  flux,  1  oz; ;  asbestos  2  oz.  ;  grinding  together 
very  finely,  completely  intermixing.  Add  granulated  body,  li 
oz.  :  and  mix  with  a  spatula  to  prevent  grinding  the  granules  of 
body  any  finer. 

"Enamels. — No.  1.  Flux,  1  oz. ;  fused  spar,  1  oz. ;  English 
rose-red,  40  grains.  Grind  English  rose-red  extremely  fine  in 
a  mortar,  and  gradually  add  the  flux  and  then  the  fused  spar, 
grinding  until  the  ingredients  are  thoroughly  incorporated.  Cut 
down  a  large  hessian  crucible,  so  that  it  will  slide  into  the 
muffle  of  a  furnace,  line  with  a  mixture  of  equal  parts  silex  and 
kaolin,  put  in  the  material  and  raise  the  heat  to  the  point  of 
vitrijication,  not  fusion,  then  Avithdraw  from  the  muflSe.  The 
result  will  be  a  red  cake  of  enamel  which  will  easily  leave  the 
crucible,  which,  after  removing  any  adhering  kaolin,  is  to  be 
broken  down  and  ground  tolerably  fine.  It  may  now  be  tested, 
and,  if  of  too  strong  a  color,  tempered  by  the  addition  of  cover- 
iny.  This  is  the  gum  which  flows  at  the  lowest  heat,  and  is 
never  used  before  soldering. 

"No.  2.  Flux,  1  oz. ;  fused  spar,  2  oz. ;  English  rose-red, 
00  grains.  Treat  the  same  as  No.  1.  This  is  a  gum  inter- 
mediate, and  is  used  upon  platina  plates. 

"  No.  3.  Flux,  1  oz. ;  fused  spar,  3  oz. ;  English  rose-red,  80 
grains.  Treat  as  the  above.  This  gum  is  used  in  making  pieces 
intended  to  be  soldered  on,  either  in  full  arches  or  in  the  sections 


TEETH    WITH    ARTIFICIAL    CONTINUOUS    GUM.  767 

known  as  block  ivorh.  It  is  not  necessary  to  grind  very  fine  in 
preparing  the  above  formulfe. 

"  Covering. — What  is  termed  covering,  is  made  by  the  same 
formulfe  as  for  the  enamel,  omittin";  the  English  rose-red. 
Being  without  any  coloring  whatever,  it  is  used  for  tempering 
the  above  enamels  when  too  highly  colored,  which  may  be  done 
by  adding,  according  to  circumstances,  from  one  to  six  parts  of 
covering  to  two  of  enamel,  thus  procuring  the  desired  shade. 
When  it  is  to  be  used  for  covering  the  base  prior  to  applying 
the  enamel,  it  may  be  colored  with  titanium,  using  from  two  to 
five  grains  to  the  ounce. 

"  Investient. — Take  two  measures  of  white  quartz  sand,  mix 
with  one  measure  of  plaster  of  paris,  using  just  enough  water 
to  make  the  mass  plastic,  and  apply  quickly.  The  slab  on  which 
the  piece  is  set  should  be  saturated  with  water  to  keep  the  ma- 
terial from  setting  too  soon,  and  that  it  may  unite  with  it. 

"  Memoranda. — In  preparing  material,  ahvays  grind  dry,  and 
use  the  most  scrupulous  cleanliness  in  all  the  manipulations. 
In  all  cases  where  heat  is  applied,  it  should  be  raised  gradually 
from  the  bottom  of  the  muffle,  and  never  run  into  a  heat. 
Where  it  is  desired  to  lengthen  any  of  the  teeth,  or  to  mend  a 
broken  tooth,  it  may  be  done  with  covering,  properly  colored 
with  platina,  cobalt  or  titanium. 

"  In  repairing  a  piece  of  work,  wash  it  with  great  care,  using 
a  stiff  brush  and  pulverized  pumice-stone.  Bake  over  a  slow 
fire  to  expel  all  moisture,  and  wash  again,  when  it  will  be  ready 
for  any  new  application  of  the  enamel.  Absorption,  occurring 
after  a  case  has  been  some  time  worn,  by  allowing  the  jaws  to 
close  nearer,  causes  the  lower  jaw  to  come  forward  and  drive 
the  upper  set  out  of  the  mouth.  By  putting  the  covering  on  the 
grinding  surfaces  of  the  back  teeth  in  sufficient  quantity  to  make 
up  the  desired  length,  this , difficulty  may  be  to  some  extent 
remedied. 

"  Any  alloy,  containing  copper  or  silver,  should  not  be  used 
for  solder  or  plate,  if  it  is  intended  to  fuse  a  gum  over  the  lingual 
side  of  the  teeth,  as  it  will  surely  stain  the  gum.  Simple  platina 
backs  alone  do  not  possess  the  requisite  stiffness,  and  should 
always  be  covered — on  platina  with  the  enamel,  and  on  gold 
with  another  gold  back.     In  backing  the  teeth,  lap  the  backs, 


768  TEETH    WITH    ARTIFICIAL    CONTINUOUS    GUM. 

or  neatly  join  them  up  as  far  as  the  lower  pin,  in  the  tooth,  and 
higher  if  admissible,  and  in  soldering  be  sure  to  have  the  joint 
so  made  perfectly  soldered.'' 

The  compositions  originally  employed  by  Dr.  Allen  consist  of 
— Body:  silex,  2  oz.;  flint  glass,  1  oz. ;  borax,  1  oz.;  wedge- 
wood  ware,  H  oz. ;  asbestos,  2  drachms;  feld-spar,  2  drachms; 
kaolin,  1  drachm.  Enamel:  feld-spar,  |  oz. ;  white  glass,  1  oz. ; 
and  oxide  of  gold,  1^  grs.  Since  the  publication  of  the  seventh 
edition  of  this  work,  great  improvements  have  been  made  by  Dr. 
Allen  in  the  composition  and  preparation  both  of  the  body  and 
gum  enamel,  which  are  furnished  by  the  manufacturers  and  may 
be  obtained  at  any  of  the  dentists'  furnishing  establishments  at 
a  very  moderate  price. 

The  metals  which  may  be  employed  for  the  base  in  this  method 
of  mounting  artificial  teeth,  are,  platina  or  pure  palladium. 
The  common  commercial  article  of  palladium  is  not  pure,  and  is 
never  used  in  this  country.  Platina,  alloyed  with  from  one  to 
ten  per  cent,  of  pure  gold  may  also  be  used,  but  it  is  objection- 
able from  its  liability  to  spring  or  warp.  It  makes  a  stiffer 
plate,  and  so  far  has  the  advantage  over  pure  platina,  but  for 
the  reason  given  the  purest  metal  should  be  selected.  Because 
of  its  softness,  it  must  be  used  thicker  than  gohl  plate. 

The  process  of  swaging  the  plate  is  the  same  as  before  given. 
It  must  be  often  annealed,  and  gradually  carried  into  any  deep 
depressions,  for  its  softness  makes  it  more  liable  than  gold  to  be 
torn,  made  thin,  or  punched  through.  A  narrow  rim  partially 
turned  up  is  to  be  left  around  the  outside.  The  process  of 
articulating,  etc.,  is  similar  to  that  for  gold. 

In  adjusting  the  teeth  accurate  grinding  is  unnecessary,  but 
each  tooth  should  touch  the  plate.  Part  of  each  backing  should 
lap  over  the  adjoining  ones,  and,  behind  the  six  front  teeth, 
should  also  be  lapped  over  an  additional  narrow  band,  to  give 
greater  rigidity  to  the  plate.  In  this  process,  there  is  great 
opportunity  to  give  to  the  teeth  that  irregularity  of  arrangement 
\vlii<li  forms  one  of  the  characteristics  of  natural  teetii ;  neglect 
ot  which  gives  to  many,  otherwise  excellent  pieces  of  work,  an 
unnatural,  artificial  appearance,  that  shows  great  deficiency  in 
the  cultivation  of  dental  cesthetics. 

Before  backing  the  teeth,  the  piece  may  be  tried  in  the  mouth, 


TEETH    WITH    ARTIFICIAL    CONTINUOUS    GUM.  759 

and  any  inaccuracy  of  articulation  readily  corrected.  After 
they  are  backed,  the  piece  should  be  set  in  a  mixture  of  plaster 
and  asbestos  (Dr.  Allen  prefers  asbestos  to  sand),  resting  on  a 
muffle-slide,  and  coming  up  around  the  outside  of  the  teeth  to 
keep  them  in  place.  The  solder  used  must  contain  no  trace  of 
either  silver  or  copper,  as  they  will  stain  the  gum-enamel  and 
body,  but  must  be  either  pure  gold,  or  alloyed  with  about  five 
per  cent,  of  platina.  Borax  may  be  used,  not  in  this  case  as  a 
flux,  for  where  there  is  no  oxidation  no  flux  is  required,  but  to 
tack  the  pieces  of  solder  to  place  until  ready  to  flow.  The  slide 
is  then  gradually  carried  into  the  muffle,  and  the  whole  piece 
raised  to  the  melting  point  of  the  solder. 

The  form  of  furnace,  and  rules  for  the  management  of  the 
heat,  are  the  same  as  before  given  for  block-work.  The  heat 
required  for  this  is  not,  however,  so  great  as  that  required  m 
block-work ;  the  gold  and  the  continuous  gum  materials  fusing 
at  about  2200°  Fahrenheit. 

Having  thus  soldered  and  cooled  off"  the  piece  very  gradually, 
it  must  be  thoroughly  washed,  so  as  to  remove  every  particle  of 
investment.  Then  with  a  camel's-hair  brush  and  small  knife, 
such  as  is  used  in  block-carving,  the  spaces  between  the  teeth 
and  plate  are  to  be  perfectly  filled  with  a  finely  compacted 
paste  of  bod^  and  rain  Avater.  The  paste  must  be  applied  very 
moist,  so  as  to  exclude  the  air  and  run  into  all  the  spaces;  then 
dried  with  cloth  or  blotting-paper,  and  compressed  with  the 
knife.  If  the  lingual  surface  of  the  plate  is  to  be  covered,  this 
should  be  made  rough  by  soldering  small  clippings  of  platina 
over  it,  at  the  time  the  teeth  are  soldered.  The  natural  rugae 
of  the  palate  should  be  imitated  in  the  thin  layer  of  body  which 
is  applied. 

The  work  must  then  be  slowly  and  thoroughly  dried,  and  the 
piece  put  on  a  slide  with  the  coronal  ends  of  the  teeth  downward 
and  imbedded  to  the  depth  of  about  an  eighth  of  an  inch  in  a 
thick  batter  of  plaster  and  asbestos.  But  if  the  teeth  are  very 
securely  soldered,  it  will  be  best  to  flow  the  body  with  the  plate 
resting,  teeth  upward,  on  the  plaster  and  asbestos  model  on  which 
the  soldering  was  done.  The  slide  is  then  gradually  introduced 
into  the  muffle,  and  subjected  to  a  heat  sufficiently  high  to  fuse 
the  compound — say,  twenty-two  hundred  and  fifty  degrees.  It 
is  then  withdrawn  slowly,  and  completely  cooled.     Usually  there 


760  TEETH    WITH    ARTIFICIAL    CONTINUOUS    GUM. 

will  be  cracks  and  flaws  which  need  filling  with  paste.  The 
outside  rim  is  also  to  be  turned  down  over  the  edge  of  the  body 
with  hammer  and  ])liers,  and  any  defects  at  this  point  filled  up; 
then  heat  a  second  time  with  the  same  care  as  at  first. 

The  piece,  now  ready  for  enameling,  should  present  a  semi- 
vitrified  appearance ;  if  too  highly  glazed,  it  is  too  much  done, 
and  the  enamel  will  not  take  so  firm  a  hold ;  if  too  dull-looking, 
it  is  not  sufficiently  baked,  and  will  be  deficient  in  strength. 
The  enamel  must  be  ajjplied  moist,  and  is  best  put  on  with  a 
brush:  much  plastering  with  the  knife  makes  it  apt  to  "fly"  in 
baking,  and  for  the  same  reason  it  must  be  heated  very  gradually. 
The  layer  of  enamel  should  be  thin  and  irregular,  the  yellowish 
white  of  the  body  showing  more  or  less  through  it,  so  as  to 
give  the  variations  of  tint  observed  in  the  natural  gum.  If  a 
thick  and  even  layer  is  applied,  the  result  will  be  an  unnatural 
uniform  color,  which  will  destroy  much  of  the  peculiar  beauty  of 
this  work. 

The  greatest  care  is  necessary,  in  applying  the  paste,  to  re- 
move every  particle  from  the  parts  of  the  teeth  and  plate  which 
are  not  to  be  covered,  as  it  adheres  with  great  tenacity,  and 
roughens  and  disfigures  these  parts.  Much  experience  is  also 
necessary  in  determining  the  exact  heat  necessary  to  develop 
the  full  beauty  and  strength  of  the  work.  Repeated  heatings, 
either  for  the  first  making  or  for  repairs,  do  not  injure  the  plate 
or  teeth,  provided  proper  care  is  taken  to  heat  and  cool  gradu- 
ally ;  and  provided,  in  case  of  repair,  the  piece  is  thoroughly 
cleansed  in  strong  soda,  to  remove  all  trace  of  the  buccal 
secretions. 

This  work  is  peculiarly  adapted  to  full  lower  dentures.  The 
principles  of  construction  are  precisely  the  same,  only  the  plate 
should  be  very  heavy,  and  the  extra  band  behind  the  six  or  eight 
front  teeth  very  thick  and  strong.  Many  use  it  for  partial 
cases;  for  which,  how^ever,  the  author  does  not  regard  it  as  well 
suited. 

The  three  distinguishing  advantages  of  the  continuous  gum 
work  are  its  ready  adaptability  to  every  variety  in  shape  of 
gum  and  arrangement  of  teeth,  its  great  beauty,  and  its  extreme 
cleanliness :  its  three  disadvantages  are,  its  weight,  its  liability 
to  be  broken  by  accident,  and  its  inapplicability  to  partial  cases. 


CHAPTER     EIGHTEENTH. 


APPLICATION  OF  VULCANIZED  INDIA-RUBBER  TO 
DENTAL  PURPOSES.* 

The  process  of  hardening  India-rubber  by  combinins:  it  with 
sulphur  and  subjecting  to  heat,  as  patented  by  Mr.  Goodyear, 
was  in  use  for  a  number  of  years  before  its  application  to  dental 
purposes  Avas  attempted.  It  was  thus  used  as  early  as  1853. 
Mr.  Bevan,  a  former  employee  of  the  Goodyear  Company,  Dr. 
Putnam,  of  New  York,  and  Dr.  Mallett,  of  New  Haven,  were 
the  first  persons  known  to  the  writer  as  engaged  in  these  experi- 
ments. It  is  quite  possible,  however,  that  others  Avere  at  the 
same  time  thus  occupied. 

Owing  to  the  exceedingly  cumbrous  nature  of  the  apparatus 
(Dr.  Putnam's  weighed  twelve  hundred  pounds),  and  the  absence 
of  that  knowledge  of  the  material  and  those  appliances  for  its 
manipulation  which  experience  alone  could  give,  it  made,  for  a 
few  years,  very  sIoav  progress.  It  has  been  estimated  that,  in 
1858,  not  more  than  three  hundred  dentists  made  any  use  of  it : 
whereas,  in  1863,  it  is  conjectured  by  Dr.  B.  W.  Franklin  (the 
Dental  Agent  for  the  American  Hard  Rubber  Company,  which 
claims  the  right  to  all  applications  to  the  Goodyear  "  hard  rub- 
ber" patents),  that  nearly,  if  not  quite,  three  thousand  employ 
it  more  or  less  extensively  in  their  practice. 

India-rubber  is  the  concrete  juice  of  several  tropical  plants, 
but  is  obtained  chiefly  from  the  Siplionia  cahuea,  growing  in 
South  America  and  Java.  It  is  obtained  by  tapping  the  trees, 
and  is  at  first  of  a  yellowish-white  color,  but  darkens  rapidly  on 

••••  This  chapter  has  been  prepared  by  Professor  Austen,  at  the  request  of  the  publish- 
ers, and  in  fulfillment  of  a  promise  once  given  to  his  late  highly  esteemed  friend  and 
colleague,  President  Harris.  Into  the  controversies  which  the  introduction  of  the 
vulcanite  has  given  rise  to,  the  writer  has  neither  wish  nor  intention  to  enter ;  but 
will,  after  a  brief  review  of  the  materials  and  their  application  to  dentistry,  give, 
as  concisely  as  possible,  a  description  of  some  of  the  apparatus  and  manipulations 
employed  in  this  process. 

49 


7(;2  VVLCANIZED    RUBBER    PROCESS. 

exposure.  It  is  singular  that  this  substance,  now  regarded  so 
absolutely  indispensable,  should  have  been  used  for  fifty  years 
(from  1770  to  1820)  only  to  erase  pencil-marks — whence  its 
name,  rubber. 

When  once  inspissated,  no  known  means  can  restore  it  to  its 
original  milky  condition.  It  is  totally  insoluble  in  water  or 
•ilcohol:  but  with  strongest  other,  it  forms  a  colorless  solution. 
In  hot  naphtha,  it  swells  to  thirty  times  its  bulk ;  and,  when 
triturated  in  a  mortar  and  pressed  through  a  sieve,  forms 
a  water-proof  varnish  for  cloth.  It  melts  at  248°  F.,  and  re- 
mains fluid  without  change  up  to  500°  F.,  and  burns,  when  ignited, 
with  a  bright,  but  smoky,  flame. 

Cold  sulphuric  acid  and  dilute  nitric  acid  affect  it  slightly ; 
the  strongest  caustic  potash  does  not  act  upon  it,  nor  do  chlo- 
rine, ammonia,  fluo-silicic  acid  and  many  other  powerful  agents; 
hence  its  great  value  in  the  chemical  laboratory.  Of  its  many 
uses  we  shall  refer  only  to  that  class  due  to  the  properties  de- 
veloped by  its  combination  with  sulphur  or  sulphur  compounds, 
selecting  for  description  that  variety  of  this  combination  pre- 
pared for  dental  purposes,  and  known  as  dental  vulcanite. 

The  crude  imported  rubber  is  cut  into  minute  shreds  by  knives 
set  on  revolving  cylinders,  and  thoroughly  washed.  It  is  then 
dried  and  Avarmed  and  kneaded  with  twenty-five  per  cent,  (by 
weight)  of  sulphur  and  twenty -five  per  cent,  of  best  quality  of  Ver- 
million. The  intensity  of  the  color  of  the  vermillion  overcomes 
the  jet  (or  deep  brown)  black  of  the  sulphur  and  rubber  when 
vulcanized,  and  gives  it  a  color  more  generally  acceptable;  it 
;ils(t  lessens  the  time  required  for  vulcanizing.  The  rubber,  sul- 
phur and  vermillion  are  all  opa([ue  substances,  and  can  never 
themselves,  or  by  any  combination  with  other  substances,  be 
made  to  assume  any  resemblance  to  the  natural  gum,  which  por- 
celain alone  has,  thus  far,  been  able  to  imitate.  The  incorpora- 
tion of  other  substances  for  this  purpose  has  no  other  effect 
than  seriously  to  impair  the  strength  of  the  material.  Hence, 
in  artificial  dentures,  the  rubber  must  be  kept  out  of  sight. 

The  question  of  the  medicinal  action  of  the  vermillion  (sul- 
phuret  of  mercury)  used  in  vulcanite,  is  now  the  subject  of  ac- 
tive inquiry.  After  a  few  years  of  careful  observation  on  the 
part   of  those   who   know   how  to  distinguish  results   from   se- 


VULCANIZED    RUBBER    PROCESS.  763 

quences,  we  shall  be  enabled  to  decide  this  question  on  what 
Hippocrates  and  Sydenham  considered  the  only  true  basis  of 
medicine — namely,  experience.  Meanwhile,  each  person  inter- 
ested in  the  question  should  aim  to  gather  his  quota  of  cases; 
the  more  extended  the  generalization,  the  more  accurate  will 
be  the  inferences  deduced  from  it. 

As  it  is  an  important  point,  and  one  to  which  the  student's 
attention  should  be  directed,  I  shall  give  the  result  of  my  own 
experience ;  also  my  reasons  for  doubting  whether  the  sulphuret 
of  mercury,  in  combination  Avith  the  sulphur  and  rubber,  can 
exercise  any  injurious  constitutional  effects  ;  having  given  the 
subject  a  very  careful  investigation  long  before  my  attention 
was  called  to  the  discussions  in  the  journals. 

First,  no  symptom  following  the  use  of  vulcanite  plates  has, 
in  any  single  case,  come  under  my  observation,  indicating  local 
or  constitutional  medicinal  action;  but  the  experience  of  one 
person,  although  sufficient  to  prove  the  possibility  of  an  occur- 
rence, cannot,  by  any  rule  of  logic,  establish  the  impossibility  of 
any  asserted  statement.  I  shall  therefore  give,  secondly,  a  few 
reasons  for  believing  in  the  improbability  of  any  medicinal 
action  of  the  vulcanite. 

Pure  sulphuret  of  mercury  is  reckoned  by  Orfila  as  medici- 
nally inert.  Fumigation,  by  vaporizing  the  mercury,  gives  it  a 
medicinal  activity ;  but  this  requires  a  temperature  of  600°  F. 
Therefore,  for  the  development  of  constitutional  symptoms,  we 
must  have  the  presence  of  arsenic  or  of  red-lead  as  impurities 
of  the  sulphuret ;  or  the  existence  of  free  mercury. 

First,  as  to  the  impurities  of  arsenic  or  red-lead ;  they  are 
not  found  in  pure  vermillion.  But  even  if  present,  such  poison- 
ous impurity  would  be  rendered  harmless,  because  completely 
invested  by  an  insoluble  coating  of  India-rubber.  A  piece  of 
vulcanite  is  impervious  to  the  fluids  of  the  mouth ;  hence,  no 
part  of  its  substance  can  be  dissolved,  and  thus  taken  into  the 
stomach.  Any  supposed  medicinal  action  must,  therefore,  come 
from  such  minute  particles  as  may  possibly  be  worn  off  the  lin- 
gual surface  near  the  teeth  where  bread-crusts  or  other  hard 
particles  of  food  impinge.  We  have  thus  an  almost  infinitesi- 
mally  small  quantity  of  vulcanite  taken  into  the  stomach,  one- 
third  of  which  is  inert  vermillion,  adulterated  (we  will  suppose) 


764  VULCANIZED    RUBBER    PROCESS. 

with  three  per  cent,  of  arsenic,  and  this  coated  with  a  layer  of 
rubber,  wliich,  as  previously  stated,  is  insoluble  in  water,  alco- 
hol, alkalies,  or  weak  acids.  This  very  minute  trace  of  arsenic, 
even  if  divested  of  its  envelope  of  rubber,  would  have  a  purely 
homoeopathic  (and,  by  consequence,  not  poisonous)  action  ;  whilst, 
if  encased  in  rubber,  which  pervades  every  part  of  the  material, 
it  is  absolutely  inert.  The  same  may  be  said  of  the  less  poison- 
ous adulteration,  red-lead. 

Secondly,  as  to  the  mercury,  the  researches  of  my  colleagues, 
Professor  Johnston,  with  the  microscope,  and  Professor  Mayer, 
by  chemical  analysis,  have  failed  to  discover  the  slightest  trace 
in  samples  of  the  rubber  used  by  me  during  several  years.  I 
have  failed  by  any  mechanical  force  to  press  out  any  globules, 
nor  have  I  ever,  in  all  my  manipulations,  seen  the  slightest  par- 
ticle of  this  metal,  or  been  able  with  the  microscope  to  detect 
it  upon  the  surface  of  any  finished  piece.  The  one  point,  there- 
fore, wliich  I  would  suggest  as  calling  for  an  extended  series  of 
thorough  experiments  and  analyses  is  the  presence  of  free  mer- 
cury in  the  vulcanized  material,  for  this  I  regard  as  the  only 
agent  that  can  possibly  exert  any  deleterious  action  upon  the 
system.  That  its  presence  is  rare,  I  consider  proven;  but  that 
it  is  never  found,  can  only  be,  Avith  any  propriety,  asserted  or 
denied  after  the  extended  observations  recommended,  the  ob- 
servers being  able  to  distinguish  the  minute  crystals  of  sulphur 
from  globules  of  mercury. 

The  materials  of  dental  vulcanite  are  thoroughly  kneaded  by 
hand  and  then  rolled  out  into  sheets  for  use,  and  in  this  form  it 
comes  into  the  hands  of  the  dentist.  I  shall  now  proceed  to 
specify  those  points,  in  the  progress  of  the  manipulations  from  the 
impression  onward,  that  require  modification  in  their  application 
to  the  vulcanite. 

Impressions,  with  few  exceptions,  must  be  taken  in  plaster. 
The  minute  accuracy  of  plaster  is  not  so  essential  in  swaging, 
since  the  very  fine  lines  of  the  model  are  partly  lost  in  the  die, 
and  could  not  be  impressed  on  the  plate ;  but  in  the  vulcanite, 
the  faintest  scratch  is  faithfully  copied.  Hence,  also,  the  finest 
plaster  must  be  used,  and  stirred  until  all  air-bubbles  are  re- 
moved. The  absolute  necessity  of  plaster  impressions,  in  par- 
tial cases  where  vulcanite  is  used,  led  me  to  devise  the  method 


VULCANIZED    RUBBER    PROCESS.  765 

elsewhere  described,  of  using  gutta-percha  cups.  The  advan- 
tages of  a  partial  plaster  impression  thus  obtained  are — first,  the 
exact  shape  of  the  outside  of  the  teeth,  each  side  the  space  to 
be  filled,  permits  correct  adjustment  upon  the  model;  secondly, 
the  accurate  shape  of  the  outside  of  the  molars  and  bicuspids,  at 
the  point  where  wax  impressions  "drag,"  allows  the  stays  or 
half-clasps  to  be  closely  fitted  to  the  teeth ;  thirdly,  the  preci- 
sion with  which  plaster  copies  the  gum  enables  the  operator  to 
dispense  with  any  vacuum  cavity.  But  it  must  be  borne  in 
mind,  that  partial  impressions  in  plaster  and  partial  pieces  in 
vulcanite  demand  for  their  success  the  utmost  care  and  nicety  of 
manipulation;  a  care,  however,  which  the  result  will  fully 
reward. 

Models  require  no  particular  shaping,  except  the  extension  of 
the  back  part  an  inch  or  more,  so  that  the  model  itself  may 
serve  as  one-half  of  the  articulator.  This  not  only  saves  time 
and  plaster,  but  gives  more  accurate  results :  when  the  teeth  are 
set  in  the  wax  plate,  the  model  is  then  separated  with  a  saw 
from  the  back  part  and  placed  in  the  flask.  In  double  sets,  the 
back  part  of  one  model  is  smoothed,  and  the  T  shaped  groove 
cut  and  soaped ;  the  extension  of  the  other  model  is  left  rough, 
and  when  the  articulating  plates  are  made,  the  models  are  set 
into  their  respective  plates  and  the  space  at  the  back  part  filled 
with  plaster.  Partial  models  containing  a  number  of  teeth  require 
no  other  antagonizer  than  a  model  made  from  a  simple  impres- 
sion in  wax  of  the  lower  teeth,  which  will  fit  the  irregularities 
of  the  teeth  of  the  upper  model.  Models  for  vulcanite  may  be 
coated  with  very  dilute  soluble  glass,  but  no  other  varnish  is 
admissible. 

Antagonizing  plates  are  made  by  moulding  a  piece  of  gutta 
percha  over  the  model,  kept  very  wet  to  prevent  adiiesion.  The 
central  part  of  the  plate  should  be  thick  to  give  stiff"ness  to  the 
plate;  the  rim  on  the  ridge  should  be  the  exact  length  of  the 
teeth  required,  and  trimmed  on  the  outside  to  give  the  proper 
fullness.  In  a  lower  set,  the  rim  should  be  stiffened  with  a  piece 
of  heavy  iron  wire.  In  a  full,  or  nearly  full,  upper  set,  the 
impress  of  the  lower  teeth  is  to  be  received  in  a  thin  rim  of  wax 
set  on  the  gutta-percha.  In  a  double  set,  the  rims  are  trimmed 
till  they  touch  uniformly,   and  then  their  relation  marked  by 


766  VULCANIZED    RUBBER    PROCESS. 

indentations  across  the  line  of  contact.  It  is  quite  possible, 
with  ffutta-percha  plate-s,  to  take  the  articulation  with  such 
accuracy  that  no  trial  of  the  teeth  is  necessary,  and  little  if  any 
grinding  of  the  teeth  upon  inserting  them  in  the  mouth. 

Preparatory  to  grinding,  the  thick  articulating  plates  must  be 
removed,  and  thinner  ones  substituted  of  wax  or  gutta-percha ; 
placing  a  little  foil  or  thin  sheet-lead  upon  the  ridge,  against 
which  to  grind  and  fit  the  teeth,  except  in  those  cases  where  the 
tooth  is  required  to  fit  against  the  gum  without  any  intervening 
rubber.  The  wax  plate  should  be  from  the  twelfth  to  the 
twentieth  of  an  inch  in  thickness ;  and  as  the  teeth  are  ground 
they  should  be  tacked  to  it  with  softened  or  melted  wax.  In 
grinding,  the  greatest  care  must  be  taken  to  make  close  joints; 
but  the  fitting  of  the  base  requires  none  of  the  accuracy  de- 
manded in  fitting  gold  plates,  except  when  the  tooth  is  to  be  set 
directly  upon  the  gum. 

It  is,  however,  a  mistake  to  suppose  that  a  space  of  half  an 
inch  can  with  perfect  impunity  be  left  between  the  teeth  and 
plate.  The  vulcanite  has  a  slight  shrinkage  on  cooling.  Unlike 
the  shrinkage  of  metal,  which  is  irresistible,  that  of  vulcanite  is 
controlled  by  the  matrix,  so  that  it  results  in  no  change  in  the 
shape  of  the  plate.  This  is  proved  by  the  closeness  with  which 
it  is  seen  to  adhere  to  the  model  on  opening  the  matrix.  But 
it  takes  place  in  th^e  direction  of  the  thickness  of  the  plate.  If, 
therefore,  a  large  bulk  of  material  is  interposed  between  the 
teeth  and  ridge,  it  will  shrink  perceptibly  either  from  the  ridge  or 
from  the  teeth ;  in  the  first  case  impairing  the  fit  of  the  piece, 
in  the  latter  case  loosening  the  hold  of  the  rubber  upon  the 
tooth.  It  is  not  impossible  that  subsequent  modifications  in  the 
timt'  and  manner  of  vulcanizing  may  correct  this  and  several 
other  difficulties  attendant  on  the  hardening  of  very  thick 
masses  of  rubber ;  meanwhile  it  is  safer  to  avoid  all  unnecessary 
clumsiness. 

After  grinding  and  arranging  the  teeth,  the  wax  must  be  care- 
fully worked  with  a  wax-knife  (constantly  warmed  in  a  small 
alcohol  flame),  i)lacing  wax  just  where  the  rubber  is  required,: 
and  avoiding,  for  the  reason  just  given,  all  excess  of  wax.  This 
process  is  sometimes  tedious,  but  the  time  will  be  more  thai 
saved  in  the  process  of  finishing. 


VULCANIZED    RUBBER    PROCESS.  767 

All  forms  of  teeth  may  be  used  with  the  vulcanite  base,  and, 
unlike  most  other  work,  may  be  used  again  and  again.  Con- 
tinuous gum  teeth  can  be  strongly  and  handsomely  arranged, 
provided  the  patient  shows  but  little  of  the  tooth.  Single, 
plain  and  gum  teeth  require  either  to  be  backed  with  gold  strips 
and  soldered,  or  simply  to  have  the  pins  lengthened.  For  this 
purpose  heavy  platina  wire,  say  No.  20,  should  be  cut  into 
lengths,  from  one-fourth  to  three-fourths  of  an  inch  long,  set 
between  the  pins  in  the  required  direction,  and  soldered  Avith 
pure  gold. 

But  teeth  made  expressly  for  the  work  are  more  convenient. 
Of  these  an  extensive  assortment  is  now  offered  by  the  manu- 
facturers. The  pin  in  these  teeth  is  either  made  longer  than  in 
a  plate  tooth,  or  it  is  headed.  The  former  requires  to  be  bent 
and  roughened,  and  will  answer  very  well  for  blocks  containing 
several  pins.  But  the  headed  pin  is  to  be  preferred  in  most 
cases,  and  will  hold  the  tooth  firmly,  provided  it  does  not  set  too 
closely  to  the  tooth,  and  the  rubber  is  not  too  thick  and  clumsy. 
In  the  first  case  it  will  break  away ;  in  the  second  it  will  be 
loose,  from  the  shrinkage  of  the  mass  of  rub- 
ber. Fig.  269  gives  a  very  correct  idea  of  ^"'-  ^*^^*- 
an  excellent  form  of  tooth,  with  these  double- 
headed  pins,  designed  and  manufactured  by 
Dr.  S.  S.  White. 

The  subsequent  steps  are   peculiar  to  the 
vulcanite  process,  and  demand  a  preliminary 
description  of  the  apparatus,  including  the  vulcanizer  or  heater, 
flasks,  lamp,  and  fixtures  for  packing  and  clamping  the  flasks. 

From  the  first  vulcanizing  apparatus,  weighing  1200  pounds, 
and  requiring  the  constant  care  of  an  engineer.  Dr.  Putnam 
reduced  the  size  and  weight  to  a  stove  and  boiler  weighing  about 
350  ;  then,  in  connection  with  Mr.  Warren,  he  brought  it  down  to 
100,  which  was  considered  the  highest  improvement  of  cast-iron 
vulcanizers.  The  substitution  of  copper,  first  made  by  Mr. 
Brown,  of  Buffalo,  addod  to  the  strength,  reduced  the  weight, 
and  permitted  the  substitution  of  flame  heat  for  coals.  Some 
of  the  vulcanizers  now  in  use  weigh  only  four  and  a  half 
pounds. 

There  is  a  limit  to  all  things,  and  this  has,  in  my  judgment, 


768 


VULCANIZED    RUBBER    PROCESS. 


Fig. 


l>een  passed  in  the  attempt  to  provide  the  smallest  and  lightest 
apparatus  possible.  Those  heaters  are  best  which  will  hold  two 
or  three  pieces,  with  space  aronnd  for  water,  which  should 
alwavs  cover  the  flasks.  The  flasks,  which  ordinarily  are  made 
entirely  too  small,  should  be  able  to  hold  the  largest  cases  with 
ease. 

Fig.  270  represents  one  of  the  small  vulcanizers  of  Dr.  Hayes, 
of  Bnff'alo,  which  claims  to  vulcanize  one  piece  in  40  minutes,  at 

320°,  with  only  one  ounce  of  al- 
cohol.    It  is  a  beautiful  specimen 
of   ingenuity    and    workmanship; 
but  I  much  prefer  his  three-flask 
vulcanizers — run  for  a  longer  time 
and  at  a  lower  temperature.     As 
to  whether  one  or  ten  ounces  of 
alcohol    are    consumed,    is    alto- 
gether unworthy  of  consideration. 
Not    that    unnecessary    extrava- 
gance should  be  encouraged  ;  but 
dental   art  has   suff"ered  much   from  that   spirit  of  economy  in 
the  Kiboratory  which  puts  33  per  cent,  of  alloy  in  gold  plate, 
Fig.  271.  deals  in  cheap  teeth,  and  thinks 

more  of  petty  savings  of  material 
than  of  making  work  which,  by 
its  beauty  and  durability,  may 
prove  creditable  both  to  the  pro- 
fession and  to  the  practitioner. 

Fig.  271  represents  a  very  sim- 
ple form  of  copper  vulcanizer, 
flasks  and  clamp  which  I  have  used 
for  the  last  three  years  with  much 
satisfaction.  I  have  heated  with 
£  gas  and  various  forms  of  alcohol 
lamp ;  but  much  prefer  a  par- 
tially self-regulating  lamp,  which 
consumes  four  ounces  of  alcohol 
— two  for  heating  up  and  two  to 
maintain  the  heat.  This  lamp  I 
devised,    upon    hearing   a  friend 


VULCANIZED    RUBBER    PROCESS. 


769 


describe  the  principle  of  construction  of  Dr.  B.  W.  Franklin's 
self-regulating  lamp,  (Fig.  272.)  It  is  simply  a  shallow  tin  cup, 
with  a  division  across  the  centre ;  a  tube  runs  from  each  half,  six 
inches  from  the  lamp,  ending  in  two  wicks  made  of  bundles  of 
finest  wire  spread  at  the  top  according  to  the  size  of  flame  re- 
quired, the  larger  of  these  is  for  heating  up,  the  smaller  one  is 
so  trimmed  as  to  keep  the  heat  uniformly  at  the  required  point. 
This  lamp  does  away  with  the  necessity  of  a  safety-valve,  as 
explosion  is  impossible.  But  I  cannot  agree  with  those  who 
think  that  the  thermometer  also  may  be  dispensed  with,  or  that 
variations  of  a  few  degrees  make  no  difference  in  the  result. 
Alcohol  will  be  found  to  be  the  best  material  for  heating  up,  and 
a  lamp  like  Dr.  Franklin's  very  valuable  indeed,  as  it  makes  un- 
necessary the  constant  watching  otherwise  required.  But  the 
progress  of  every  heating  should  be  from  time  to  time  observed. 
The  quantity  of  water,  the  number  of  pieces  in  the  heater,  some 
accidental  derangement  of  the  metallic  wick,  and  variations  in 
the  temperature  of  the  room,  are  all  modified  agencies  which 
may  effect  the  result.  Whereas,  with  a  thermometer  and  oc- 
casional watching,  the  same  degree  of  heat  will  in  the  same  lot 
of  rubber  produce  uniformly,  a  material  having  the  same  elas- 
ticity, color  and  hardness.  Dr.  Franklin's  self-acting  lamp  is 
represented  in  Fig.  272,  giving  an  internal  and  external  view.  A 

Fig.  272. 


minute  description  of  the  lamp  and  its  mode  of  operation  can 
be  obtained  from  the  inventor.  Figs.  273  and  274  represent  the 
form  of  vulcanizer  and  flask,  to  which  the  size  of  the  wicks  in 
this  lamp  are  adjusted. 

What  form  of  vulcanizing  apparatus  is  best,  can  be  ascertained 
only  by  giving  all  a  trial.  The  simple  forms  above  given,  are 
excellent,  and  will  yield  under  proper  management  perfect  and 


770 


VULCANIZED    RUBBER    PROCESS. 


uniform  results.     Possibly  others  may  be  better  ;  nor  is  it  at  all 
improbable,  that  inventive  genius,  now  very  busy  in  this  branch 

Fig    273. 


Fig.  274. 


of  dental  machinery,  will  bring  forth  something  superior  to  any 
now  in  use  ;  but  the  limits  of  this  chapter  do  not  permit  a  full 
inquiry  into  the  details  of  construction.  I  shall  now  give  the 
manipulations  necessary  for  preparing  the  model,  with  teeth 
arranged  upon  it,  for  the  vulcanizer. 

Set  the  model  in  plaster  in  the  lower  half-flask  A,  (see  Fig.  275. ) 
first  saturating  it  with  water  to  prevent  the  too  rapid  setting  of 

Fig.  27."). 


the  plaster.  Trim  smoothly  up  to  the  model ;  soap  this  surface, 
or  varnish  and  oil  it,  or  cover  it  with  tin  foil ;  then  set  on  the 
upper  half-fla.sk  C,  and  pour  in  a  thin  batter,  stirring  it  well  be- 
fore pouring,  and  working  the  plaster  with  a  feather  into  every 
interstice  :  then  set  on  the  cover  D,  and  apply  the  clamp  B. 
Before  it  quite  hardens,  wash  off"  the  plaster  with  a  sponge,  from 
the  outside  of  the  flask,  and  let  it  get  quite  hard  l)efore  separat- 
ing the  two  halves ;  if  there  is  any  undercut,  or  in  case  of  a 
thin  lower  ridge,  warm  the  flask  so  as  to  soften  the  wax.      Re- 


VULCANIZED    RUBBER    PROCESS.  771 

move  the  wax  carefully,  and  the  flasks  then  present  the  appearance 
shown  in  Fig.  276 ;  the  model-half  E  separating  from  the  teeth  and 

Fig.  276. 


wax,  contained  in  the  dental-half  H.  If  the  joints  are  not  very 
closely  fitted,  place  a  little  dry  plaster  over  each  and  touch  with 
a  drop  of  water  or  diluted  soluble  glass,  and  when  hard,  trim  off 
the  surplus  plaster.  Some  prefer  to  pack  wdth  tin  or  gold-foil. 
Without  some  such  precaution,  in  open  joints,  the  rubber  will 
press  through  and  present  an  unsightly  appearance. 

In  partial  cases  where  no  vulcanite  is  required  outside  the 
arch  and  above  the  teeth,  I  find  it  most  convenient  to  carry  the 
plaster  of  the  model  half  over  the  teeth,  retaining  them  in  con- 
tact with  the  model.  In  which  case  it  Avill  be  better  to  use  the 
deep  half  H  (Fig.  276,)  for  the  model,  so  that  the  plaster  around 
the  teeth  may  come  level  with  or  slightly  above  the  edge.  The 
teeth  are  thus  firmly  fixed  in  their  exact  position,  and  resist  dis- 
placement, which  the  separation  of  the  flasks  or  the  pressure  of 
the  rubber  might  possibly  occasion.  In  this  way,  should  the 
flasks  chance  not  to  come  perfectly  together,  the  result  will  be 
an  extra  thickness  of  plate. 

It  is  desirable,  however,  in  all  cases,  and  quite  essential  in 
most,  that  the  flasks  should  come  perfectly  together.  This  is 
accomj)lished  by  attention  to  three  points:  softernng  the  rubber, 
using  a  proper  quantity,  and  having  vents  for  the  surplus.  For 
the  first  1  use  a  large  sauce-pan  capable  of  holding,  if  required, 
six  half  flasks  over  about  an  inch  of  water.  When  the  flasks 
are  thoroughly  heated  by  the  steam,  the  rubber  is  placed  on  the 
cover  of  the  sauce-pan,  and  then,  Avhile  soft,  packed  with  a 
pointed  stick  aud  fingers  into  the  dental-half  of  the  matrix. 
Around  the  teeth  the  rubber  is  packed  in  the  form  of  very  nar- 
row strips  with  points  of  hard  wood,  somewhat  as  foil  is  inserted 


772  VULCANIZED    RUBBER    PROCESS. 

into  a  cavity.     The  remainder  is  packed  either  in  large  strips, 
or  in  one  piece  cut  to  the  shape  of  the  Avax  plate. 

The  second  point  gives  much  trouble  ;  since  too  little  vulcanite 
spoils  the  piece,  and  too  much  requires  a  pressure  which  may 
break  the  blocks,  displace  the  teeth,  prevent  the  flasks  from 
coming  together,  or  force  rubber  into  the  joints.  In  most  cases 
tlic  quantity  can  be  correctly  found,  by  having  the  sheets  of 
vulcanite  exactly  as  thick  as  the  wax  plate,  removing  the  latter 
as  carefully  as  possible,  and  marking  off  its  size  on  the  former. 
But  some  irregularly  shaped  cases,  and  most  lower  cases  will  not 
admit  of  this  method.  In  these,  I  advise  the  following  simple 
method.  Let  the  plate  be  entirely  of  wax  ;  remove  it  all  from 
the  matrix  and  roll  it  into  a  sheet  the  thickness  of  the  rubber  ; 
cut  the  rubber  a  little  larger  than  this,  then  cut  into  strips  and 
pack,  bearing  in  mind  to  put  most  at  those  points  where  the  wax 
was  thickest. 

But  the  third  point  must  not  be  neglected;  for  the  error  in 
quantity  should  always  be  on  the  safe  side  of  excess,  and  provi- 
sion must  be  made  for  escape  of  this  surplus  by  cutting  vents  (H), 
as  seen  in  Fig.  276,  that  the  halves  of  the  matrix  may  come 
together  Avithout  too  great  pressure.  It  is  both  imprudent  and 
unnecessary  to  make  any  greater  pressure  than  can  be  obtained 
with  the  thumb  and  fingers  upon  the  screw  of  the  clamp  (B) 
(Fig.  275),  avoiding  excess  of  rubber,  and  having  it  heated  to 
212°  Fahrenheit. 

The  flasks,  when  screwed  down,  are  then  transferred  to  the 
vulcanizing  clamp  (Fig.  271),  and  set  into  water  in  the  vulcan- 
izer.  This  water  should  be  at  the  same  temperature  as  the 
flasks,  to  avoid  all  possible  danger  of  cracking  the  teeth.  The 
top  is  then  to  be  scrcAved  on,  and  the  heating-up  flame  applied. 
It  IS  highly  important  that  the  vulcanizer  should  be  steam-tight, 
and  the  packing  sound  and  securely  placed.  The  bursting  of  a 
good  vulcanizer  is  impossible ;  but  it  occasionally  happens  that 
the  packing,  from  imperfection  or  carelessness,  blows  out.  The 
packing  is  often  needlessly  spoiled  by  screwing  down  Avith  too 
much  force,  or  when  the  rubber  is  hot.  A  good  one,  carefully 
used,  Avill  last  six  or  twelve  months,  but  it  may  be  Avorn  out  in 
as  many  heatings. 

The  time  occupied  in  heating  up  and  vulcanizing  varies  Avith 


VULCANIZED    RUBBER    PROCESS.  773 

different  operators.  Drs.  Mallet,  Putnam  and  other  early  ex- 
perimenters vulcanized  for  six  hours  or  more.  By  gradually 
raising  the  heat  and  reducing  the  time,  they  subsequently  vul- 
canized in  three  hours  at  310°  Fahrenheit.  More  recently,  the 
error  has  been  to  vulcanize  too  quickly  at  a  high  heat. 

Dr.  Franklin  recommends  heating  slowly  at  first,  bringing  it 
in  one  hour  up  to  310°  Fahrenheit,  where  it  is  to  be  kept  uni- 
formly for  two  and  a  half  or  three  hours.  His  more  recent  ex- 
periments "  have  demonstrated,  that  if  one  hour  is  taken  to 
raise  slowly  to  300°,  and  another  full  hour  to  raise  steadily  and 
gradually  to  320°,  five  minutes"  longer  will  complete  the  vul- 
canizing." As  thermometers  vary  much,  and  the  rubber  used 
also  varies,  the  best  plan  is  for  every  one  to  vulcanize  trial  pieces 
until  the  required  hardness,  toughness  and  elasticity  is  obtained. 
It  should  curl  under  the  scraper  like  horn,  permit  bending  at  an 
angle  of  at  least  45°,  and  return  to  its  original  shape  unchanged. 
My  practice  is,  to  heat  up  in  thirty  minutes  to  325°  Fahrenheit, 
and  keep  it,  with  great  exactness,  at  that  point  for  ninety  mi- 
nutes, the  vulcanizer  being  perfectly  steam-tight  and  the  pieces 
under  water.  New  rubber,  or  a  new  thermometer,  may  call  for 
a  modification  of  these  figures.  Long  and  low  heats  give  a 
better  material  than  very  quick  and  high  heats.  One  hour  and 
a  half  after  the  vulcanizing  point  is  gained  is,  perhaps,  as  short 
a  time  as  is  consistent  with  the  development  of  the  best  proper- 
ties of  the  rubber;  but  the  material  seems  equal,  in  all  respects, 
to  that  prepared  when  I  was  in  the  habit  of  vulcanizing  for  three 
hours  at  300° — 310°.  My  experience  with  short  high-pressure 
heats  has  not  been  satisfactory,  and  I  have  not,  as  yet,  had  the 
opportunity  to  test  Dr.  Franklin's  latest  suggestions.  This  point, 
however,  in  common  with  many  others  in  the  vulcanite  work,  is 
open  to  modification  by  a  more  extended  experience. 

Upon  expiration  of  the  time,  the  flame  is  extinguished  and 
the  vulcanizer  cooled  gradually  as  it  stands;  or  more  rapidly 
either  by  the  escape  of  the  steam,  or  by  setting  the  lower  three- 
fourths  of  the  vulcanizer  in  cold  water.  The  last  method  of 
rapid  cooling  is  preferable,  running  the  heat  five  minutes  longer 
than  when  slow  cooling  is  practiced.  Letting  off  steam  is 
a  very  disagreeable  process,  and  makes  the  plaster  of  the  flasks 
very  hard  to  cut  out.     In  no  case  should  the  flasks  themselves 


774  VULCANIZED    RUBBER    PROCESS. 

lie  cooled  bv  contact  with  cold  water,  as  some  might  chance  to 
penetrate  to  the  blocks  and  crack  them. 

It  is  best  to  remove  the  plaster,  &c.,  from  the  flasks  within 
one  or  two  hours  after  vulcanizing.  After  that  time,  the  plaster 
assumes  a  sand-like,  granular  state,  and  adheres  with  great  te- 
nacity to  the  plate.  Tapping  the  edges  of  the  flasks,  after  sepa- 
ration, will  dislodge  their  contents  in  mass.  The  plaster  can 
then  be  trinnned  from  the  piece,  taking  care  that  it  is  perfectly 
cold.  The  adherent  plaster  in  the  dental-half  of  the  flask  can 
easily  be  washed  from  tlie  piece  with  a  stifi"  brush ;  but  the 
model-half  leaves  a  coating,  that  clings  very  tenaciously,  unless 
means  are  taken  to  prevent  it.  Soluble  glass  measurably  pre- 
vents this;  but,  better  still,  a  dilute  ethereal  solution  of  collodion. 
Dr.  Barker's  preparation,  sold  for  this  purpose,  answers  admira- 
bly, and  saves  much  trouble  in  cleaning  up  the  piece. 

The  process  of  finishing  is  more  troublesome  than  in  the  case 
of  gold  plate.  Several  sizes  of  round  and  half-round  files  are 
necessary  for  finishing  up  the  edges  and  convex  surfaces;  for 
the  concave  surfaces,  scrapers,  graving-chisels  and  curved  files. 
SuflBcient  thickness  must  be  left  in  the  body  of  the  plate  for 
strength,  but  the  edges  should  be  chamfered  off".  yV  pair  of 
spring-callipers  are  required  to  measure  the  thickness  of  the 
plate,  if  it  is  to  be  reduced  by  files  and  scrapers.  Much  labor 
at  this  stage  is  saved  by  an  accurate  shaping  of  the  wax.  Some 
operators  next  use  sand-paper  or  emery-cloth ;  others  use  pumice- 
stone  on  cork  wheels ;  I  always  use,  and  very  decidedly  prefer, 
Scotch-stone.  The  third  step  is  the  use  of  rotten-stone  (not 
tripoli.  which  cuts  with  too  keen  a  grit),  either  on  a  brusli  wheel, 
with  tallow  or  oil,  which  is  the  more  rapid  process;  or  on  a  stick 
of  some  hard  wood,  with  water,  which  is  the  more  cleanly.  A 
little  oxide  of  zinc  on  a  soft  wheel,  or  on  the  finger,  will  give  a 
brilliant  finishing  polish,  but  is  not  essential,  as  the  rotten-stone 
can  be  made  to  polish  very  highly. 

After  trying  the  piece,  and  finding  that  no  part  of  the  edge 
requires  alteration,  a  bright  surface-color  may  be  given  by 
placing  the  piece  in  alcohol  and  exposing  to  the  sun's  rays  for 
six  or  twelve  hours.  Some  regard  this  an  improvement.  It  cer- 
tainly does  not  injure  the  quality  of  the  plate,  but  my  own  taste 
l»refers  the  original  mahogany  color  to  the  bright  vermillion  tint 
thus  given. 


VULCANIZED    RUBBER    PROCESS.  775 

In  partial  cases,  it  will  prevent  accident  if,  after  filing  the 
edges,  a  lump  of  gutta-percha  is  fitted  to  the  palatine  surface  of  the 
plate.  The  subsequent  operations  can  be  conducted  more  ra- 
pidly, and  with  less  danger,  in  delicately-shaped  pieces.  Vulcanite 
is  softened  by  heat;  hence  a  piece  is  sometimes  bent  by  revolv- 
ing the  brush-wheel  too  rapidly.  A  piece  that  has  been  in  any 
way  bent  or  warped,  may  be  restored  by  heating  either  in  boil- 
ing salt  water,  or  in  oil  to  about  220°  or  230°.  While  soft,  it 
may  be  bent  with  the  fingers ;  but,  as  this  guess-work  method  is 
hazardous,  it  is  much  better  to  bind  it  down  upon  a  model,  which 
is  also  warmed. 

Vulcanite  plates  do  not  require,  either  in  full  or  partial  cases, 
any  vacuum  cavity;  but  it  may  be  Avell,  in  some  full  cases,  to 
relieve  the  pressure  upon  a  hard  palate,  when  combined  with  a 
soft  alveolar  ridge.  This  may  be  done  by  cutting  away  the 
impression,  building  a  layer  of  plaster  on  the  model,  or  cutting 
out  the  vulcanite.  The  last  method  is  the  best,  because  it  can 
thus  be  done  only  when  found  necessary.  The  second  method 
is,  to  cover  the  inside  of  the  model  with  a  thin  wax  plate,  cut 
out  the  size  of  the  cavity,  roughen  and  wet  the  model  at  this 
place,  and  apply  a  thin  layer  of  plaster ;  when  hard,  remove  the 
wax,  and  if  necessary  trim  the  plaster  projection. 

Vulcanite  work  may  be  repaired  by  removing  the  broken 
tooth  or  block,  cutting  dovetails  in  the  rubber,  and  then  filling 
the  space  with  the  new  teeth,  arranging  the  wax  and  vulcanizing 
as  at  first.  The  part  of  the  plate  under  the  broken  teeth  should 
be  filled  with  plaster,  and  then  removed  so  as  to  preserve 
the  shape  of  the  ridge  in  case  the  process  of  repair  requires 
that  the  plate  shall  be  cut  entirely  through  at  this  point :  it  is 
to  be  replaced  before  applying  the  wax. 

The  second  heatinjj;  darkens  the  old  rubber,  and  makes  it 
more  brittle;  ])ut  full  cases  will  admit  of  one,  possibly  two  such 
heatings.  Partial  cases  should  be  repaired  either  by  re])hicing 
the  entire  plate  with  new  rubber,  or  riveting  on  a  gold  or  platina 
slip,  to  which  the  new  tooth  is  soldered.  I  decidedly  prefer,  in 
both  full  and  partial  cases,  the  entire  replacement  of  the  rubber. 
In  doing  this,  there  are  various  ways  of  securing  the  correct 
relation  of  the  teeth  to  the  new  model.      1  shall  name  only  two. 

First,  in  cases  where  the   plaster  model   can   be  drawn  from 


776  VULCANIZED    RUBBER    PROCESS. 

the  plate — fill  the  palatine  surface  of  the  plate  after  a  Tery 
slit^ht  oiling;  let  the  model  have  a  projecting  flange  outside  the 
arch;  soap  or  varni.<h  this  flange  (which  should  have  depressions 
cut  into  it),' and  run  plaster  upon  this  and  against  the  outside  of 
the  teeth  :  remove  this  plaster  rim,  then  heat  the  plate  in  a  sand- 
bath  or  hot  oil,  and  take  off  the  teeth  ;  adjust  the  outside  rim  of 
plaster  to  the  model,  set  the  teeth  in  their  respective  places, 
and  apply  wax,  etc.,  as  at  first,  and  prepare  for  vulcanizing. 
Soraetiuie:?  in  partial  cases  gutta-percha  may  be  used  instead  of 
plaster  to  secure  the  relation  of  the  teeth  to  the  model.  The 
central  portion  of  the  old  plate  may  be  generally  used  again 
instead  of  a  new  wax  plate. 

Secondly,  in  cases  where  the  model  cannot  be  drawn  from  the 
plare,  and  also  in  those  cases  where,  from  defect  in  the  first 
impression,  a  new  one  is  necessary.  In  some  partial  cases,  the 
new  plaster  impression  gives  a  model  which  makes  a  second 
arrangement  of  the  teeth  perfectly  easy.  In  other  partial 
cases,  and  in  full  sets — run  a  plaster  rim  around  the  outside  of 
the  teeth  ;  remove  it,  and  then  soften  the  plate  and  detach  the 
teeth  ;  replace  the  teeth  in  the  plaster  rim,  then  bend  a  stout 
iron  wire  so  as  to  touch  along  the  inside  of  them,  and  fasten 
each  tooth  or  block  to  the  wire  with  cement  (resin,  gutta-percha 
and  plaster);  remove  the  plaster  rim,  then  set  the  teeth  upon 
the  new  model,  and  arrange  new  wax  plate,  etc. ;  detach  the 
wire  with  a  hot  wax-knife,  and  chip  off  the  fragments  of  brittle 
cement  as  gently  as  possible,  so  as  not  to  derange  the  position 
of  the  teeth.  Special  cases  will  call  for  modifications  of  these 
processes,  of  which  the  limits  of  this  chapter  will  not  permit  a 
description.  This  method  of  repairing  by  the  substitution  of  a 
new  plate  (although  sometimes  very  simple)  is  often  but  little 
less  troublesome  than  the  original  work,  the  only  labor  saved 
being  in  the  grinding  of  the  teeth. 

Partial  pieces  can  usually  be  retained  by  stays  and  the  fit  of 
the  plate.  If  clasps  are  called  for,  these  may  be  made  in  some 
cases  of  rubber  alone;  but  still  better  of  rubber  strengthened 
by  a  gold  wire,  which  is  to  be  placed  around  the  clasp-tooth,  just 
before  packing  the  rubber.  A  gold  clasp  may  also  be  fitted  and 
retaine<l  m  the  rubber,  either  by  a  projecting  slip  of  the  same 
metal,  or  by  soldering  into  it  one  or  two  platina  pins. 


1 


VULCANIZED    RUBBER    PROCESS.  777 

Blocks  or  gum  teeth  may  be  secured  to  gold  plate  by  vulcanite 
instead  of  soldering.  One  method  of  doing  this  has  been  made 
the  subject  of  a  patent  by  Dr.  A.  M.  Asay  &  Son,  of  Philadelphia, 
the  details  of  which  can  be  obtained  by  reference  to  them. 
Blocks  with  holes  passing  partly  or  entirely  through  the  teeth, 
can  be  very  firmly  secured  by  vulcanite.  Solder  roughened  or 
lieaded  pins  into  the  plate  opposite  each  hole;  fasten  the  blocks 
temporarily  with  wax,  then  invest  in  the  vulcanizing  flasks,  so 
that  on  separating  the  matrix  the  plate  shall  come  away  in  one 
half,  the  teeth  in  the  other  ;  fill  the  holes  with  rubber,  and  place 
A  Strip  over  the  base  of  the  blocks ;  warm  and  replace  the  two 
!ialves  of  the  matrix,  and  vulcanize. 

Vulcanite  blocks  may  be  set  on  gold  plates  thus — grind  and 
fit  accurately  to  the  plate ;  run  a  plaster  rim  on  the  outside  of 
the  blocks,  then  remove  the  wax  and  mark  on  the  plate  proper 
points  for  the  insertion  of  platina  loops  or  headed  pins;  remove 
the  teeth  and  solder  these  loops  or  pins  into  holes  punched  or 
rlrilled  in  the  plate;  re- adjust  the  teeth  in  the  plaster  rim,  and 
fasten  them  in  place,  with  wax  trimmed  to  the  shape  required 
for  the  vulcanite  ;  then  invest  in  the  flask  and  vulcanize  as  be- 
fore described. 

This  is  a  very  useful  application  of  vulcanite.  It  loses  one  of 
the  peculiar  advantages  of  the  vulcanite,  the  accurate  fit  of  the 
plate.  But  it  makes  very  strong  work,  and  is  more  cleanly  than 
ordinary  swaged  work  because  all  interstices  are  so  completely 
closed.  It  obviates  two  of  the  principal  objections  urged  against 
vulcanite — thickness  of  the  plate,  and  contact  of  the  rubber 
against  the  gum  and  tongue.  It  also  dispenses  with  the  accu- 
rate grinding  of  the  base  of  the  blocks,  required  in  ordinary 
gold  work,  and  obviates  the  risks  of  the  soldering  process.  I 
think  that  by  the  use  of  an  outside  band,  either  swaged  or 
soldered,  and  a  soldered  inside  lining,  thus  showing  merely  a 
narrow  line  of  rubber,  the  greatest  opponent  of  the  vulcanite 
would  find  this  one  of  the  very  best  means  of  securing  blocks 
or  gum  teeth  to  gold  plate,  for  all  full  cases  and  those  partial 
cases  where  three  or  four  teeth  are  grouped  together. 

Of  the  peculiar   adaptation  of  the  vulcanite  material  to  the 
correction  of  irregularity  mention  has  been  made  on  p.  160  of 
50 


778  VULCANIZED    RUBBER    PROCESS. 

this  work.  No  further  special  directions  are  required,  except 
on  two  points  :  first,  to  have  the  phister  Avhich  makes  the  model 
perfectly  smooth  and  free  from  air  bubbles ;  secondly,  to  coat 
the  teeth  before  vulcanizing  with  Barker's  solution.  Attention 
to  these  two  points  will  give  a  plate,  that,  if  the  impression  is 
correct,  will  fit  the  teeth  with  most  perfect  accuracy. 

It  remains  briefly,  to  refer  to  the  application  of  the  vulcanite 
to  the  pivoting  of  teeth.  Several  methods  of  doing  this  are 
given  by  Prof.  J.  Richardson  in  the  April  No.  of  the  Dental 
Begutei\  1862,  to  which  the  reader  is  referred.  My  own  method 
is  concisely  as  follows — prepare  the  root  as  elsewhere  directed 
in  this  Avork,  (p.  615,)  being  careful  to  drill  the  hole  in  the  root, 
as  smoothly  and  uniformly  as  possible ;  wrap  some  gutta-percha 
around  a  small  piece  of  wire,  pass  into  the  pivot  hole  and  harden 
it  by  applying  cold  water  on  a  piece  of  cotton.  The  piece  of 
gutta-percha  may  either  be  large  enough  to  cover  the  base  of 
the  root  Or  may  be  removed  and  trimmed  to  the  size  of  the  hole, 
a  looped  end  of  the  wire  being  left  projecting  below.  Now  take 
carefully  a  plaster  impression  of  the  space  and  two  adjacent 
teeth,  let  it  get  very  hard,  then  withdraw  it.  The  gutta-percha 
pin  is  held  in  the  plaster  by  the  wire  loop  and  drawn  away  with 
it.  A  plaster  model  is  made  from  this,  the  plaster  impression 
very  carefully  removed,  and  the  pin  softened  and  removed  from 
the  pivot  hole. 

This  model,  made  of  finest  plaster  and  well  mixed,  is  hardened 
with  dilute  soluble  glass,  and  forms  the  basis  on  which  to  adjust 
and  finish  any  kind  of  tooth  that  may  be  thought  best,  or  that 
the  shape,  size  or  direction  of  the  pivot  hole  in  the  root  may 
require.  Selecting  a  vulcanite,  plate  or  pivot  tooth,  it  is  ground 
to  fit  accurately  in  front.  If  a  pivot  tooth  is  used,  I  prefer  to 
grind  the  lingual  surface  with  a  very  small  wheel,  until  the  pivot 
hole  is  opened  through  the  tooth.  Then  pass  a  gold  wire 
through  the  tooth  into  the  plaster  pivot  hole ;  arrange  the  wax, 
set  the  case  in  the  flask,  separate,  pack  with  rubber  and  vul- 
canize. In  case  of  a  plate  or  vulcanite  tooth,  set  the  wire  in 
the  hole  in  the  plaster  and  cover  the  part  projecting  with  wax 
built  against  the  back  of  the  tooth. 

If  the  canal  in  the  root  is  large  and  I  wish  to  line  it  with 
vulcanite,   I   take  a  gold   pin  perfectly  cylindrical   and    highly 


1 
I 


VULCANIZED    RUBBER    PROCESS.  779 

polished  and  roughen  the  part  below  the  root ;  then  set  the 
polished  end  centrally  in  the  hole  in  the  plaster  and  proceed  as 
before.  When  vulcanized  and  finished  up,  I  cut  with  a  sharp 
knife  around  the  base  of  the  pin  down  to  the  gold  pin  and  then 
insert  the  piece  in  the  mouth.  Sliould  it  be  necessary  to  remove 
the  tooth,  the  smooth  gold  pin  will  draw  from  the  rubber  before 
the  detached  cylinder  will  draw  from  the  tooth. 

Again,  should  I  prefer  to  use  the  wooden  pivot,  I  take  a  small 
polished  brass  or  steel  pin  that  fits  the  root  exactly,  but  not 
tightly;  with  this  set  in  the  hole  in  the  plaster  and  projecting 
one  quarter  of  an  inch  or  more,  proceed  to  arrange  wax,  and 
vulcanize  as  before.  When  polished  up,  the  metal  pin  is  re- 
placed with  compressed  hickory  and  inserted. 

The  use  of  vulcanite  in  pivot  teeth  gives  greater  firmness  by 
exactly  fitting  the  base  of  the  root.  By  thus  excluding  the  se- 
cretions, it  also  removes  another  objection  to  pivoting.  The 
method  above  recommended  enables  the  operator  to  complete 
the  work,  after  taking  the  impression,  in  the  absence  of  the  pa- 
tient, and  yet  with  absolute  accuracy. 

Upon  the  completion  and  insertion  of  a  vulcanite  piece,  the 
patient  should  be  cautioned  to  cleanse  it  at  least  once  a  day  with 
a  stiff  tooth-brush  and  water.  Extreme  cleanliness  is  advisable 
in  all  kinds  of  artificial  work,  and  many  patients  need  no  such 
direction.  The  special  necessity  for  this  in  the  case  of  vulca- 
nite arises  from  the  tenacity  with  which  the  mucous  secretions 
of  the  mouth  adhere  to  the  surface  if,  from  neglect,  they  are 
allowed  to  collect  upon  it.  It  is  most  apt  to  collect  at  those 
points  wdiere  the  friction  of  the  tongue  and  of  the  food  does  not 
prevent  it.  The  same  care  is  necessary  for  its  daily  removal  as 
is  required  to  keep  the  natural  teeth  in  good  order.  There  is, 
however,  this  difi'erence  between  cleanliness  of  the  teeth  and  of 
the  plate,  that  while  both  are  essential  to  purity  of  the  mouth, 
the  secretions  have  no  chemical  action  upon  the  plate,  as  they 
have  upon  the  teeth. 

There  is  one  point  affecting  the  durability  of  vulcanite  plates 
which  it  remains  for  subsequent  experience  to  settle.  It  is  well 
known  that  silver  and  eighteen-carat  gold  undergo  a  change 
in  the  mouth,  which  causes  them  to  become  more  or  less  brittle. 


780  VULCANIZED    RUBBER    PROCESS. 

This  is  not  the  case  with  twenty-carat  gohl  and  with  platina.  A 
similar  change  is  noticeable  in  the  gutta-percha  which  is  used  for 
impressions,  and  is  found,  also,  in  the  vulcanized  gutta-percha 
and  in  tliose  preparations  of  vulcanized  rubber  with  which 
foreiffn  substances  are  hirgely  mixed,  in  the  vain  hope  of  giving 
it  some  resemblance  to  the  natural  gum.  I  have  failed,  as  yet, 
to  detect  it  in  the  "Goodyear  compound"  of  India-rubber,  sul- 
phur and  vcrniillion.  But  this  point  requires  the  collected  ex- 
perience of  many  obseivers,  carried  ovci'  a  period  of  years, 
carefully  distinguishing  between  the  brittleness  of  over-baking 
nr  tAvice  vulcanizing,  and  that  which  may  supervene  as  the  re- 
■^ult  of  certain  molecular  changes  in  the  substance  of  the  material. 
It  is  a  change  which,  unlike  the  galvanic  change  in  gold  and  sil- 
ver plate,  does  not  require  the  presence  of  the  buccal  fluids  ; 
!)ut  will  take  place  equally  out  of,  as  in,  the  mouth,  as  is  shown 
in  the  case  of  gutta-percha.  It  is  a  point,  also,  which  is,  doubt- 
less, much  modified  by  the  manner  of  vulcanizing.  Slow  and 
careful  vulcanizing  will,  probably,  give  entire  freedom  from  the 
liability  to  become  brittle  by  age. 

In  conclusion,  it  may  not  be  amiss  to  give,  briefly,  the  present 
status  of  the  vulcanized  rubber  process.  Upon  the  subject  of 
patents  in  general  or  the  validity  of  special  patent-rights  it  is 
not  necessary  to  express  any  opinion.  This  is  purely  a  ques- 
tion of  law  and  political  economy,  with  which  dental  teaching 
has  nothing  to  do.  But  it  has  much  to  do  with  the  inquiry  into 
the  merits  of  a  process,  the  use  of  which  has  spread  during  the 
last  three  years  with  an  unexampled  rapidity,  eliciting,  on  the 
one  hand,  unqualified  a[)proval ;  on  the  other,  unsparing  con- 
ilemnation. 

Against  the  use  of  the  vulcanite  it  is  urged:  First.  That  it 
degrades  the  art,  by  the  temptation  it  off"ers  for  cheap  work,  and 
by  the  ease  with  which  its  peculiar  manipulations  are  performed. 
t?econd.  That  its  medicinal  action  upon  the  system  is  such  as 
renders  it  an  unfit  material  to  be  put  into  the  mouth.  Third. 
That  it  produces  an  unpleasant  burning  or  heating  sensation  in 
the  mucous  membrane,  and  a  permanent  sponginess  of  the  gums, 
not  found  after  the  wearing  of  metallic  plates.  Fourth.  That 
the  mucous  secretions  recjuire  more  care  for  their  removal  from 


VULCANIZED    RUBBER    PROCESS.  781 

the  surface  of  the  phite  than  most  patients  are  in  the  habit  of 
giving;  hence  the  liability  of  the  piece  to  become  unpleasant. 
Fifth.  That,  to  give  the  necessary  strength,  requires  a  thickness 
of  plate  that  is  clumsy  and  interferes  with  distinctness  of  enun- 
ciation. Sixth.  That  the  work  becomes  brittle  in  the  course  of 
a  few  years.  Seventh,  That  it  is  troublesome  to  repair  in  such 
a  way  as  to  maintain  its  original  strength. 

In  favor  of  the  use  of  vulcanite,  it  is  urged:  First.  That  the 
absolutely  perfect  and  unfailing  accuracy  of  its  adaptation  to 
the  model  places  it,  in  this  important  respect,  before  every  other 
material  in  use  for  dental  plates..  Second.  That,  being  perfectly 
impervious  to  fluids  and  insoluble,  it  is  a  pure  and  harmless  ma- 
terial. Third.  That,  being  devoid  of  all  galvanic  action,  it  is 
more  agreeable  to  patients  than  soldered  and  alloyed  plates. 
Fourth.  That  it  has  none  of  the  wearing  action  of  metal  upon 
teeth,  against  which  it  becomes  necessary,  in  partial  cases,  to 
bring  it  in  contact.  Fifth.  That  the  great  lightness  of  the  mate- 
rial makes  it  very  pleasant  to  the  patient,  and  permits  the  filling 
out  of  deficiencies  in  the  ridge  with  the  least  possible  addition 
to  the  weight  of  the  piece.  Sixth.  That  this  lightness,  together 
with  its  peculiar  elasticity,  lessens  greatly  the  danger  of  acciden- 
tal breakage  of  either  teeth  or  plate ;  thus  making  it,  when  pro- 
perly constructed,  the  strongest  of  all  dental  substitutes.  Se- 
venth. That  the  plastic  properties  of  the  vulcanite  and  the 
readiness  with  which  it  may  be  moulded  and  hardened  against 
any  surface,  however  irregular,  give  it  a  wider  range  of  applica- 
bility than  any  other  substance  used  in  dentistry. 

As  stated  at  the  commencement  of  this  chapter,  it  is  not  my 
purpose  to  discuss  any  of  these  points  further  than  they  have 
been  necessarily  referred  to  in  the  description  of  materiuls  and 
processes.  None  of  them  can  be  settled  by  argument,  and  the 
amount  of  experience  as  yet  collected  is  inadequate  to  decide 
them  all. 

Present  manipulations,  materials  and  apparatus  in  this  com- 
paratively new  process  will,  doubtless,  be  more  or  less  modified, 
and  some  of  the  objections  now  urged,  Avith  more  or  less  truth, 
against  its  use  will  be  done  away  with.  But  so  valuable  are  its  pecu- 
liar  properties,  tliat  the  vulcanized  India-rubber,  in  some  form  or 
mode  of  application,  must,  unquestionably,  become  imeparahle 


782  VULCANIZED    RUBBER    PROCESS. 

from  dental  practice.  Its  introduction  forms  one  of  those  marked 
eras  in  dental  prosthesis,  prominent  among  which  may  be  men 
tioned — the  manufacture  of  porcelain  teeth ;  the  use  of  metallic 
swaged  plates;  the  use  of  plaster  for  impressions;  the  applica- 
tion of  the  principle  of  atmospheric  pressure;  the  continuous 
gum  work ;  lastly,  the  vulcanite.  Neither  the  material  itself,  the 
process  of  hardening,  nor  the  apparatus  used  are,  as  yet,  perfect, 
and  the  various  applications  of  this  valuable  substance  to  dental 
purposes  are  as  yet  but  partially  knoAvn.  The  ignorant  and  un- 
skillful will  do  it  discredit  by  badly  working  and  by  misapplying 
it.  Meanwhile  the  scientific  and  philanthropic  practitioner  will 
patiently  investigate  its  properties,  in  the  hope  that,  perchance, 
it  may  supply  some  want  of  suffering  humanity  which  dental 
art  has.  as  yet,  been  unable  to  relieve. 


CHAPTER     NINETEENTH. 

CHEOPLASTIC  PROCESS.* 

Among  tlie  peculiar  advantages  claimed  for  the  Oheoplastic 
method  of  mounting  artificial  teeth  over  the  usual  method  with 
swaged-plates,  are  perfect  accuracy  of  adaptation  of  the  plate  to 
the  plaster  model,  (metallic  castings  not  being  used  in  this  pro- 
cess,) and  greater  practical  usefulness  and  durability:  also 
that  it  can  be  done  in  less  time,  and  that  the  material  used  in 
this  process  is  less  expensive.  This  material  is  an  alloy,  the 
precise  composition  of  which  we  have  never  taken  trouble  to 
ascertain,  as  it  can  be  obtained  from  the  manufacturer,  and  at 
most  of  the  dental  depots,  of  a  better  quality,  we  presume,  and 
at  a  lower  price  than  it  can  be  made  in  small  quantities.  It  is, 
however,  composed  principally  of  tin,  silver  and  bismuth,  with  a 
small  trace  of  antimony :  the  exact  proportions  of  which  may  be 
seen  in  the  specifications  which  accompany  the  application  for 
the  patent.  The  alloy  imparts  no  taste  whatever  to  the  mouth, 
and  its  purity,  so  far  as  its  capability  of  resisting  the  action  of 
the  secretions  of  the  buccal  cavity  is  concerned,  is  said  to  be  fully 
equal  to  that  of  eighteen  carat  gold.  Its  color,  after  being  worn 
some  weeks,  becomes  slightly  darkened,  but  is  immediately  re- 
stored by  placing  it  in  a  strong  solution  of  caustic  potash.  This 
is  the  only  change  we  have  ever  observed,  and  we  have  seen  it 
after  having  been  worn  in  the  mouth  nearly  two  years. 

This  method  of  mounting  teeth  has  only  been  practiced  since 
the  fall  of  1855,  and  it  was  not  made  known  to  the  profession 
generally  until  February.  1^57.  Since  this  time,  it  has  been 
more  or  less  adopted  and  practiced  by  nearly  three  hundre<l 
dentists,  among  which   number  are  many   of  tlic   most  skillful 

"  We  had  hoped  to  receive  from  Dr.  A,  A.  Bliuidy,  the  patentee  of  this  method,  a 
•statement  of  the  improvements  made  by  him  in  the  alloy  and  manipulations  peculiar  to 
his  process.  But  he  was  unexpectedly  called  frum  the  country  and  his  emendations 
i-annot  be  received  in  time  for  the  pre.-cnt  edition.  The  chapter  i.s  therefore  reprinted, 
■vith  a  few  verbal  alterati(jn.«,  u.s  it  appeared  in  the  last  edition. 


i84 


CHEOPLASTIC    PROCESS. 


practitioners  in  the  United  States.  Thus  far  we  believe  it  has 
fully  realized  the  expectations  of  its  most  zealous  advocates,  and 
judging  from  the  testimony  of  others,  as  well  as  from  results 
which  have  come  under  our  own  observation,  the  use  of  it  seems 
likely,  in  a  very  short  time,  to  become  general. 

In  mounting  artificial  teeth  by  the   Cheoplastic  process,  the 
first  thing  is  to  take  an  impression  of  the  mouth  either  with  wax 

Fig.  277. 


or  plaster  of  paris.  If  it  is  desired  to  have  a  central  chamber 
<»r  cavity  in  the  base,  with  a  view  to  make  it  adhere  more  firmly 
to  the  parts  against  which  it  is  to  rest,  one  of  the  right  size, 
depth  and  shape,  is  cut  at  the  proper  place  in  the  impression  ; 
this,  if  ot  plaster,  is  varnished,  then  placed  on  a  piece  of  paste- 
bi)ard  or  paper,  and  surrounded  with  soft  putty,  dough  or  clay,  or 
any  other  plastic  substance.  A  tin  ring  is  then  placed  over  it, 
(the  lower  edge  slightly  imbedded  in  the  putty,)  large  enough  to 
leave  a  space  of  about  half  of  an  inch  all  around  between  the  im- 
pression and  the  ring,  except  at  the  back  part,  where  it  should 
be  :iii  iiK-h  and  a  (luarter  at  least,  for  the  formation  of  an  articu- 
lating surface  for  the  two  parts  of  the  matrix,  and  that  it  may 
also  be  used  for  the  antagonizing  model.  The  rins  should  be 
about  an  inch  or  an  inch  and  a  half  in  depth.  See  Fig.  277. 
Ihe  model  is  made  of  equal  parts,  by  weight,  of  plaster  of 


CHEOPLASTIC    PROCESS.  '  785 

paris  and  finely  pulverized  spar,  mixed  with  pure  water  until  of 
the  consistence  of  thin  batter.  This  composition  is  not  so  hard 
us  plaster  alone,  but  it  is  sufficiently  solid  for  all  practical  pur- 
poses. If  desirable,  the  density  of  the  surface  may  be  increased 
by  the  use  of  dilute  soluble  glass.  The  impression  and  surface 
of  the  putty,  as  well  as  the  inside  of  the  ring  being  oiled,  the 
mixture  is  poured  in,  stirring  it  with  a  camel's-hair  pencil  or 
feather,  until  it  is  raised  to  a  level  with  the  upper  edge  of  the 
ring.  As  soon  as  it  becomes  sufficiently  hard,  the  ring  and  putty 
are  removed,  and  the  model  carefully  separated  from  the  impres- 
sion, which,  when  the  alveolar  border  has  no  undercut,  may  be 
done  without  injury  to  either.  Half  a  dozen  or  more  models 
can  often  be  taken  from  the  same  impression.  When  the  alveo- 
lar ridge  projects,  it  is  sometimes  necessary  to  cut  away  the 
outer  part  of  the  impression  before  the  separation  can  be  effected, 
but  when  this  is  done,  care  is  necessary  to  prevent  injuring  the 
model.  Having  removed  the  model  from  the  impression,  the 
portion  designed  for  the  formation  of  the  chamber  in  the  base 
may  be  altered,  if  desired,  and  made  smoother  before  proceeding 
further  with  the  operation. 

The  next  thing  to  be  done  is,  to  make  an  antagonizing  model, 
and  as  the  method  of  obtaining  it  for  this  process  is  different 
from  any  heretofore  given,  we  subjoin  a  brief  description  of  it. 
Two  or  three  conical  holes  are  made  in  the  b^ck  part  of  the 
model  for  the  proper  adjustment  of  the  antagonizing  portion, 
(see  Fig.  278,  in  which  the  artist  has  represented  the  holes  en- 
tirely too  small,)  a  coating  of  varnish  is  applied  to  every  part  except 
that  which  is  to  be  covered  by  the  base  for  the  artificial  teeth. 
This  part  is  now  covered  with  a  plate  of  thick  tin  foil,  stiffened 
by  the  application  of  a  sheet  of  soft  wax  to  the  part  within  the 
arch.  This  may  be  a  quarter  or  three-eighths  of  an  inch  thick, 
and  when  it  has  hardened,  a  rim  of  softened  wax  is  placed  along 
the  alveolar  border  and  trimmed  down  with  a  knife  until  its 
width  is  a  little  greater  than  the  length  required  for  the  artificial 
teeth.  Remove  this  and  the  stiffened  tin  foil  plate  together, 
place  them  in  the  mouth  before  tiie  wax  hardens,  and  if  the  rim 
is  of  the  right  width  all  round,  request  the  patient  to  bite  upon 
it.  closing  tlie  lower  jaw  naturally,  until  a  distinct  imprint  of  all 


786 


CHEOPLASTIC    PROCESS. 


the  lower  teeth  is  made  in  it,     (See  Fig.  278.)     This  done,  the 
wax   and  plate  are  removed  from  the  mouth,  replaced  on  the 


Fig.  'JTS. 


model,  and  the  lower  half-model  made  in  the  manner  described 
in  a  preceding  chapter. 

After  the  lower  half-model,  the  wax  and  tin  foil  have  been 
removed,  the  portion  of  the  model  representing  the  alveolar 
ridge  and  roof  of  the  mouth,  is  covered  with  a  fresh  plate  of  tin. 
This  is  accurately  moulded  to  the  various  depressions  and  prom- 
inences with  the  finger,  and  with  hard  rolls  of  chamois  leather,  cut 
nearly  to  a  point  at  each  end,  called  stumps,  (Fig.  279,)  such  as 

Fig.  279. 


arc  used  for  shading  drawings.  One  or  two  extra  strips  of  foil 
may  be  placed  over  the  prominent  parts  of  the  alveolar  ridge  to 
secure  suflScient  thickness  of  metal  at  those  points  between  the 
teeth  and  gums.  A  plate  of  sheet  wax,  rolled  to  the  thirtieth 
or  fortieth  part  of  an  inch  in  thickness,  is  put  over  the  tin,  cover- 
ing only  so  much  of  the  model  as  is  to  be  occupied  by  the  metallic 


CHEOPLASTIC    PROCESS. 


787 


base.  This  is  carefully  and  accurately  moulded  to  the  tin-foil 
plate,  and  then  trimmed  to  the  required  size.  Fig.  280  shows 
the  model  and  Avax  plate  separated. 


I 


Fig.  280. 


Fig.  281. 


The  teeth  are  now  selected  and  arranged  upon  the  wax  plate 
of  the  model.  Gum  teeth,  either  single  or  in  blocks  of  two  or 
three,  are  preferable.  As  they  are  arranged  upon  the  model, 
the  approximal  sides  are  ground  until 
the  teeth  or  blocks  come  together  so 
perfectly  at  every  point  as  to  render 
the  line  of  union  scarcely  percepti- 
ble, no  paper  being  required  between 
the  joints,  as  in  the  soldering  pro- 
cess. The  teeth  used  in  this  process 
are  constructed  differently  from  those 
designed  for   swaged    plates.     They 

are  not  provided  with  platina  pins  in  their  palatine  surface,  but 
have  holes  or  dove-tail  grooves  into  which  the  metal  runs,  re- 
taining them  securely  to  the  base.  A  sectional  view  of  single 
and  block  teeth  designed  for  this  process  is  given  in  Fig.  281, 


788  CUEUPLASTIC    PROCESS. 

tlie  shaded  line  representing  the  metal.  But  plate  teeth  can  be 
used  and  attached  very  securely  by  bending  the  platina  pins 
until  the  ends  come  together.  Dr.  Sheppard,  of  Virginia,  had 
made  by  Messrs.  Jones,  White  &  McCurdy,  and  uses  for  tliis 
process,  a  form  of  tooth  with  platina  pins,  very  similar  to  those 
now  used  for  the  vulcanite  work.  As  it  is  not  a  matter  of  any 
importance  whether  the  base  of  the  teeth  fit  closely  to  the  wax 
plate  or  not,  it  is  rarely  necessary  to  grind  them  here,  except 
when  the  teeth  are  too  long. 

Each  tooth  or  block,  after  having  been  properly  ground,  is 
made  fast  to  the  wax  plate  by  applying  melted  wax  to  the  pala- 
tine surface,  which  fills  the  holes  or  grooves  and  runs  down  and 
unites  with  the  plate  beneath.  The  instrument  constructed  for 
this  purpose  (Fig.  282)  is  to  be  previously  warmed  in   the  flame 

Fig.  282. 


of  a  spirit-lamp.  The  two  halves  of  the  antagonizing  model 
are,  from  time  to  time,  applied  to  each  other  as  the  teeth  are  ar- 
ranged, in  order  to  insure  accuracy  of  adjustment.  When  proper 
care  is  taken,  it  will  seldom  be  necessary,  if  the  bite  of  the 
lower  teeth  has  been  correctly  taken,  to  make  any  alteration  in 
the  piece  after  it  is  put  in  the  mouth.  The  amount  of  Avax  ap- 
plied to  the  backs  of  the  teeth,  after  the  grooves  or  holes  are 
filled,  should  e(iual  the  amount  of  metal  required  to  unite  them 
firmly  to  the  base.  This  may  be  done  by  putting  a  narrow  strip 
extending  all  tlie  way  round  the  inside  of  the  arch,  or  it  may  be 
applied  m  small  pieces,  in  either  case  using  the  wax-knife  (Fig. 
282)  warm,  to  unite  the  strip  or  pieces  to  the  teeth  and  wax 
plate.  Another  strip  is  next  applied  along  the  upper  edge,  on 
the  outside  of  the  teeth,  filling  the  groove  above  the  gum,  and 
uniting  it  to  the  teeth  and  plate  with  the  wax-knife.  This  strip 
should  be  long  enough  to  pass  behind  the  last  tooth  or  block  on 
each  side,  and  unite  with  the  wax  applied  along  the  lingual  surface. 
As  metal  is  ultimately  to  take  the  place  of  the  wax,  it  is  import- 
ant that  the  exact  quantity  required  be  put  on,  and  every  part 
made  perfectly  smootli.      This  may  be  done  with  the  warm  wax- 


CHEOPLASTIC    PROCESS. 


789 


knife  and  brusfhes  like  those  represented  in  Fig.  283.    The  hirger 
ones  are  designed  for  pressing  it  down  upon  the  model,  and  the 


Fio.  2? 


smaller  for  smoothing  it  betAveen  the  teeth,  and  where  the  wax- 
knife  cannot  be  conveniently  employed.  The  smoothing  process 
may  be  facilitated  by  throwing  the  flame  of  a  spirit-lamp  lightly 
over  the  wax  with  a  very  finely-pointed  blow-jjipe,  slightly  melt- 
ing the  surface  and  giving  it  a  beautifully  polished  appearance. 
In  proportion  as  this  part  of  the  operation  is  neatly  and  skill- 
fully executed,  will   the  labor  of  finishing,  after  the  metal  has 

been  poured,  be  lessened. 

Fig.  284. 


An  upper  set  of  single  gum  t(  eth,  thus  arranged  on  a  wax 
plate  upon  the  model,  is  represented  in  Fig.  284.  If  there  is  any 
doubt  Avitli  reganl  to  the  pro[)('r  adjustment  of  the  teeth,  arising 


TOO 


CUEOPLASTIC    PROCESS. 


tVoin  tVar  that  tlie  bite  of  the  lower  teeth  into  the  rim  of  wax 
wa.s  not  natural,  the  piece  may  now  be  tried  in  the  mouth ;  and 
should  any  alteration  be  necessary,  it  must  be  made  before  pro- 
cee<ling  furthoi-  with  the  work. 

When  single  teeth  without  gums  are  used,  the  strip  of  wax  in 
front  and  on  each  side  is  pressed  between  them  and  a  festooned 
appearance  given  to  it  like  the  natural  gum.     A  set  thus   pre- 

FiG.   285. 


pared,  is  represented  in  Fig.  285,  giving  an  external  view  of  the 
festooned  wax  band. 

The  work  is  now  placed  in  the  tin  ring  in  which  (Fig.  277) 
the  model  was  made — the  upper  edge  of  the  ring  projecting  about 

Fig.   286. 


a  fourth  of  an  inch  above  the  summits  of  the  teeth,  as  shown  in 
Fig.  286.     The  exposed  surfaces  of  the  model  inside  of  the  ring 


CHEOPLASTIC    PROCESS. 


791 


aiul  of  the  wax,  (but  not  of  the  teeth,)  are  to  be  well  oiled,  and 
a  mixture  of  plaster  of  paris  and  spar,  in  the  proportions  above 
given,  are  now  made  into  a  thin  batter,  and  poured  on  gradually, 
until  the  ring  is  filled,  stirring  with  the  brush  or  feather  as  be- 
fore directed,  to  drive  out  air  bubbles,  and  ensure  a  perfect  cast. 
When  the  mixture  becomes  hard,  the  ring  is  removed,  and  the 
part  of  the  matrix  first  made  is  tapped  lightly  with  a  small  ham- 
mer or  mallet  until  the  one  loosens  a  little  from  the  other,  when 
the  two  may  be  easily  separated  with  the  hands  :  but  if  there  be 
any  undercut,  thin  ridge,  or  teeth,  the  matrix  must  be  warmed 
before  separation,  so  as  to  soften  the  wax.  This  done,  while 
the  composition  is  comparatively  soft,  a  groove  or  gate  and  on 
each  side  of  it  two  vents  are  to  be  cut  in  the  back  part  of  the 
matrix,  which  contains  the  teeth  and  wax  plate;  tiirough  which 
gate  the  melted  alloy  is  to  be  poured,  the  air  escaping  through 
the  two  vents.     Fig.  287  represents  the  gate  and  vents,  also  one- 

FiR.  28". 


half  of  the  wax  plate  removed,  showing  the  ends  of  a  set  of  plain 
teeth.  All  necessary  trimming  of  the  plaster  is  done  before  the 
wax  is  removed,  to  prevent  small  pieces  from  falling  in  the 
matrix  by  the  sides  of  the  teeth.  The  wax  is  now  removed  as 
perfectly  as  possible,  as  the  absorption  of  any  considerable  por- 
tions left  in  the  matrix  has  a  tendency  to  roughen  the  surface, 
and  thus  to  prevent  the  metal  from  running  as  smoothly  as  it 
would  otherwise  do  :  but  in  the  attempt  to  remove  the  minute 
pieces,  the  excavator  will  often  roughen  the  surface  and  force 
fragments  of  plaster  into  places  from  which  they  cannot  be  re- 
moved:  these  small   remnants  of  wax  will   totally  disappear  in 


702 


CHEOPLASTIC    PROCESS. 


the  process  of  heating  up.  After  removing  the  wax,  each  half 
of  the  matrix  is  held  over  the  flame  of  a  tallow  candle,  until  a 
slight  coating  of  lampblack  forms  on  it.  The  two  parts  are  now- 
put  together  and  firmly  united  by  passing  an  iron  Avire  two  or 
three  times  around  it,  and  made  fast  by  twisting  the  ends  tightly 
together.  The  line  of  union  is  next  luted  with  a  mixture  of 
plaster  and  spar,  leaving  the  gate  and  vents  open.  This  is 
necessary  to  prevent  the  metal  from  escaping  when  poured  ;  but 
this  sometimes  requires  additional  means  of  security.  The 
simplest  and  perhaps  the  best  is,  after  wiring  and  luting  the 
matrix,  to  put  it,  with  the  gate  and  vents  upward,  into  a  sheet 

Fig.  288. 


iron  or  tin  box,  (see  Fig.  288,)  partially  filled  with  a  thick  batter 
"f  plaster  and  spar. 

Thus  secured,  the  piece  is  put  into  a  small  gas  sheet-iron 
furnace,  <>r  into  a  kitchen  range  or  bake  oven,  and  exposed  to  a 
bread-baking  heat,  say  from  :300°  to  400°  Fahrenheit,  for  from 
three  to  five  hours,  or  until  every  particle  of  moisture  is  driven 
from  it.  It  is  then  placed  in  an  upright  position,  the  metal 
melted,  and  while  at  a  temperature  sufficiently  high  to  make  it 
assume  a  light  blue  color  is  poured  quickly  into  the  matrix.  If 
It  does  not  bubble,  and  comes  up  into  the  vents  freely,  the  piece 
wdl  come  from  the  matrix  in  a  perfect  condition.  If  it  bubbles 
It  may  be  tapped  several  times  lightly  on  a  brick  or  some  hard 
Hibstanco.     When   perfectly  cohl,  the   two  parts  of  the   matrix 


CHEOPLASTIC    PROCESS.  793 

are  separated,  exposing  one  of  the  surfuccs  of  the  plate.  If  any 
part  is  found  defective,  this  is  the  proper  time  to  repair  it :  which 
is  done  with  solders  Nos.  1  and  2,  prepared  for  the  purpose,* 
muriate  of  zinc  being  used  as  a  flux.  This  latter  is  applied  to 
the  defective  part  on  the  end  of  a  small  piece  of  wood :  a  suffi- 
cient quantity  of  solder  is  then  placed  on  the  defective  part  and 
a  small  jet  of  flame  from  a  spirit  lamp  thrown  lightly  on  it  with 
a  very  finely  pointed  blow-pipe.  As  soon  as  the  solder  flows 
freely  and  smoothly,  the  projection  of  the  flame  is  immediately 
discontinued,  else  the  plate  will  be  melted. 

But  when  the  process  is  properly. conducted  from  the  beginning 
up  to  the  point  of  pouring  the  metal,  the  piece  will  come  from  the 
matrix  perfect  in  all  its  parts ;  and  when  the  metal  fails  to  flow- 
freely  around  the  teeth  and  to  cover  perfectly  the  alveolar  border 
and  palatine  arch,  it  is  better  to  melt  it  from  the  matrix  with 
the  flame  of  a  spirit  lamp  projected  upon  it  with  a  blow-pipe, 
using  the  precaution  not  to  concentrate  the  flame  too  long  on  the 
teeth,  as  in  this  case  there  would  be  danger  of  cracking  them. 
When  this  is  done,  the  matrix  is  secured  as  in  the  first  instance, 
luted,  dried  and  the  metal  again  poured. 

Before  removing  the  piece  from  the  half  of  the  matrix  which 
holds  the  teeth,  the  cavity  in  the  plate,  if  one  has  been  formed, 
is  made  smooth  with  scrapers  and  polished  with  prepared  chalk 
on  a  brush-wheel  revolved  in  a  lathe.  The  remaining  half  of  the 
matrix  is  now  removed,  and  the  edges  of  the  plate  properly 
rounded  with  a  coarse  file  ;the  asperities  of  the  exposed  surfaces 
are  removed  Avith  scrapers  made  for  the  purpose,  and  if  necessary, 
the  thickness  of  the  palatine  portion  reduced.  This  done,  these 
surfaces  are  rubbed  first  with  coarse  and  afterward  with  fine 
emery  cloth,  then  washed  in  soap  and  water,  with  a  hard  brush, 
afterward  burnished  and  finished  by  polishing  with  chalk  on  a 
brush-wheel.  The  upper  surface  of  the  plate  must  not  be  scraped 
or  polished,  as  the  accuracy  of  its  adaptation  to  the  gums  and 
palatine  arch  would  be  injured  by  it,  but  simply  washed  well 

«■  The  above  solders  are  furnished  with  the  alloy  used  for  the  base.  No.  1  is  pre- 
pared for  use  by  melting  and  pressing  it,  while  hot.  Itctween  two  smooth  flat  surfaces. 
JNo.  2  is  made  into  thin  plates  by  passing  through  a  rolling  mill.  The  flux  is  made 
by  dissolving  pure  zinc  in  muriatic  acid  until  the  acid  can  take  up  no  more  of  the 
metal.  This  flux  improves  by  age,  and  should  not  be  used,  if  possible  to  avoid  it,  for 
three  months.— Book  of  hisiiuctioux  for  Mounting  Tevth  by  the  Vhcoplaatic  Process. 

51 


794  CHEOPLASTIC    PROCESS. 

with  a  brush,  using  perhaps  a  little  whiting;  every  other  part, 
however,  oucht  to  be  finished  in  the  neatest  and  most  perfect 
manner.  The  polishing  up  to  this  point  being  completed,  the 
piece  is  put  into  a  strong  solution  of  caustic  potash,  boiled  for 
two  or  three  minutes,  then  washed  in  pure  water,  wiped  dry  and 
finished  by  re-polishing  with  chalk  and  the  brush-wheel. 

If  the  piece  is  to  be  gilded,  it  should  be  first  put  in  the  mouth 
and  worn  a  few  days,  to  ascertain  if  the  adaptation  is  perfect, 
as  any  future  alteration  would  deface  it  and  render  a  second 
covering  of  gold  necessary.  The  adjustment  being  correct,  the 
piece  is  cleansed  from  the  secretions  of  the  mouth  and  all  foreign 
matter,  by  boiling  again  in  a  solution  of  caustic  potash  and 
washed  in  pure  water ;  it  is  then  polished  with  chalk,  washed 
and  put  into  the  "gilding  solution  ;"  during  the  deposition  of  the 
gold,  it  should  be  removed  several  times,  burnished  and  polished 
to  give  solidity  to  the  plating,  and  remedy  any  defect  that  may 
be  discovered.  After  a  sufficiently  thick  coating  has  been  de- 
posited, say  from  three  to  five  dwts.,  it  is  finished  as  in  the  first 
instance,  by  burnishing  and  polishing. 

The  practical  value  of  a  piece  is  not  enhanced  in  the  slightest 
degree  by  gilding,  as  the  alloy  is  tasteless  and  is  not  acted  upon 
by  the  secretions  of  the  mouth.  Indeed,  unless  the  deposit  of 
gold  is  tolerably  thick  and  perfect  at  every  point,  it  is  produc- 
tive of  injury,  by  exciting  a  very  decided  galvanic  action.  As 
a  general  rule,  therefore,  a  piece  may  be  said  to  be  much  better 
without  than  with  it.  For  a  description  of  the  process  of  electro- 
gilding,  the  reader  is  referred  to  works  devoted  especially  to  the 
subject. 

In  mounting  a  set  of  teeth  for  the  lower  jaw  by  the  Cheoplastic 
process,  the  gate  through  which  the  metal  is  poured  into  the 
matrix  should  have  two  lateral  branches,  one  on  each  side,  to 
admit  it  more  freely  than  one  can  be  made  to  do.  The  wax 
plate  should  also  be  thicker,  to  give  sufficient  strength  and  sta- 
bility to  the  base,  but  in  every  other  respect  the  method  of 
procedure  is  almost  precisely  the  same  as  that  described  for  an 
upper  set.  For  a  partial  lower  set,  say  for  the  molars  and  bi- 
cuspids on  each  side,  the  wax  plate  should  be  extended  behind 
the  remaining  front  teeth,  and  two  or  three  thicknesses  may  be 
applied  here  to  stiffen  it  sufficiently  to  prevent  it  from  breaking 


CHEOPLASTIC    PROCESS. 


795 


Fig.  28!). 


or  bending  when  pressure  is  made  on  the  teeth  of  the  base  on 
each  side. 

In  making  an  antagonizing  model  (Fig.  289)  for  an  entire  set 
of  teeth,  the  wax  plate  for 
the  lower  jaw  is  stiffened  by 
the  adjustment  of  a  piece  of 
iron  wire  about  double  the 
•liameter  of  a  medium  sized 
knitting-needle,  bent  to  the 
curvature  of  the  arch,  and 
made  fast  to  the  inner  edge 
of  the  plate,  by  being  par- 
tiallv  imbedded  in  it.  The  rim  of  wax  is  now  arrantred  along 
the  summit  of  the  alveolar  borders,  and  after  being  properly 
trimmed,  it  is  taken  from  the  model  and  put  in  the  mouth.  The 
upper  plate  and  rim  of  wax  is  then  adjusted,  the  bite  of  the 
mouth  taken,  and  the  antagonizing  model  made  in  the  manner 
described  for  a  full  set  of  block-teeth  to  be  mounted  on  gold. 

In   Fig.  290  is  represented  a  double  set  of  teeth  arranged  in 
wax   upon   an  antagonizing  F'g-  '-90- 

model,  the  upper  and  lower 

ready  to  be  placed  upon  their   • '>'|\ 

respective    models    for    the 
formation  of  matrices. 

For  partial  sets  of  teeth 
the  Cheoplastic  process  is 
peculiarly  applicable,  the 
perfect  accuracy  of  the  adaptation  of  the  base  secures  so  firm  an 
adhesion  to  the  mouth  as  to  render  clasping  to  any  of  the  re- 
maining natural  teeth  almost  always  unnecessary.  A  single 
tooth  or  several  teeth  situated  in  diff'erent  parts  of  the  arch,  can 
be  replaced  with  the  greatest  ease,  and  they  are  so  securely  re- 
tained as  to  occasion  no  inconvenience  or  annoyance  to  the 
patient.  The  only  precaution  necessary  to  be  observed  in  their 
construction,  in  addition  to  that  of  accuracy  of  adjustment  and 
neatness  of  execution,  is  to  thicken  the  projections  of  the  wax 
plate  between  the  remaining  natural  teeth  sufficiently  to  prevent 
the  liability  to  breakage  of  the  metal  at  these  points.  These 
portions,  when  very  narrow,  should  be  made  double  the  thick- 
iicss  of  the   other  parts  of  the   plate.     After  having  adjusted 


796  CHEOPLASTIC    PROCESS. 

the  artificial  teeth,  and  made  thera  fast  to  the  wax  plate,  the 
teeth  of  the  model  should  be  cut  off  before  making  the  other 
half  i>f  the  matrix,  as  it  would  be  almost  impossible  to  separate  the 
two  halves  without  breaking  the  teeth  and  other  important  parts. 

A  piece  from  which  one  or  more  teeth  have  been  broken  can 
be  easily  repaired.  If  any  portion  of  the  tooth  remain  it  is 
removed,  and  the  metal  that  united  it  to  the  base  filed  away.  A 
new  tooth  is  selected  and  ground  until  it  corresponds  with  the 
adjoining  teeth.  The  floor  of  the  groove  filed  in  the  base  is 
covered  with  a  piece  of  wax  of  the  thickness  of  that  used  for 
the  plate  :  the  tooth  is  then  put  in  place,  wax  applied  on  the 
outside  of  the  upper  edge,  filling  the  groove  in  the  plate  ;  then 
applied  on  the  inside,  filling  the  hole  or  groove  in  the  back  of 
the  tooth,  designed  for  its  attachment  to  the  base.  This  is 
chiefly  done  with  the  wax  knife  (Fig.  282)  made  hot  in  the 
flame  of  a  spirit  lamp.  The  apex  of  a  roll  of  wax  about  an  inch 
and  a  half  in  length,  of  a  conical  shape,  is  united  to  the  wax  on 
the  back  part  of  the  tooth  :  the  apex  should  be  little  more  than 
an  eighth,  and  the  base  half  an  inch  in  diameter,  which  latter 
should  be  half  an  inch  above  the  summits  of  the  teeth.  A  small 
stem  of  wax  is  united  to  the  wax  on  the  outside  of  the  tooth, 
with  the  free  extremity  half  an  inch  above  the  tooth. 

The  sheet  iron  or  tin  ring  such  as  was  employed  in  making 
the  model,  is  now  filled  about  one-third  full  of  plaster  and  spar 
mixture,  and  the  piece  put  immediately  in  it  with  the  base  down- 
ward, pressing  upon  it  sufiiciently  to  imbed  the  concave  surface. 
A  thin  mixture  of  the  same  composition  is  then  poured  on  top, 
filling  the  ring  and  covering  the  summits  of  the  teeth  about  ii 
quarter  of  an  inch.  When  hard,  the  ring  is  removed,  and  the 
projecting  stems  of  wax  withdrawn.  The  wax  on  each  side  of 
the  tooth  and  l)etween  it  and  the  base  is  melted  out  by  throwing 
the  flame  of  a  spirit  lamp  with  a  blow-pipe  into  the  gate  behind 
the  tooth  and  the  vent  in  front. 

The  matrix  thus  formed  is  dried  and  made  hot  in  a  stove  or 
furnace,  as  in  the  first  instance.  The  alloy  is  then  melted  and 
poui-ed  into  it  through  the  gate  behind  the  tooth,  and  if  it  comes 
up.  filling  the  vent  in  front  without  bubbling,  the  piece  will  come 
from  the  matrix  perfectly  restored.  When  cold,  the  plaster  and 
spar  are  broken  from  the  teeth,  and  the  metal  around  the  new 
tooth  finished  in  the  same  manner  as  previously  described. 


PART    SEVENTH. 


DISEASES    AND    DEFECTS    OF    THE   PALATINE 
ORGANS. 


PART  SEVENTH 


DISEASES  AND  DEFECTS  OF  THE  PALATINE  ORGANS. 

Although  the  treatment  of  the  diseases  of  the  palatine  organs 
belong  more  properly  to  the  province  of  general  medicine  than 
to  the  specialty  of  Dental  Surgery ;  yet,  inasmuch  as  the  dentist 
is  often  called  upon  to  remedy  the  defects  that  sometimes  result 
from  them,-  it  is  important  that  he  should  have,  at  least,  some 
general  knowledge  of  the  morbid  phenomena  liable  to  be  devel- 
oped in  these  parts.  But  in  treating  of  these  diseases,  it  is  not 
the  intention  of  the  author  to  enter  into  a  minute  description  of 
their  pathology  or  therapeutical  indications.  His  principal 
object  is  to  notice  the  defects  resulting  either  from  malformation 
or  from  the  changes  in  structure  to  which  they  are  apt  to  give 
rise,  and  to  point  out  the  means  by  which  they  are  remedied. 

The  defects  of  the  palatine  organs  may  be  divided  into  acci- 
dental and  congenital.  The  first,  as  has  been  just  intimated, 
are  caused  by  pathological  changes  in  structure.  The  second 
are  the  result  of  malformation  or  imperfect  development  of  the 
parts.  But  from  whatever  cause  they  may  be  produced,  their 
effect  upon  the  voice,  speech,  mastication  and  deglutition  are  the 
same ;  these  functions  being  all  impaired  by  them,  in  proportion 
to  the  nature  and  extent  of  the  change.  When  they  extend  so 
far  as  to  cause  a  complete  division  of  the  hard  and  soft  structures, 
distinct  utterance  is  wholly  destroyed,  and  the  acts  of  mastica- 
tion and  deglutition  are  greatly  impaired  and  always  performed 
with  difficulty. 

When  the  loss  of  substance  is  the  result  of  disease,  and  ex- 
tends so  far  as  to  establish  a  communication  between  the  mouth 
and  nasal  fossic,  the  defect  can  seldom  be  remedied  in  any  other 
way  than  by  means  of  an  artificial   obturator.     Even  when   the 


800       DISEASES    AND    DEFECTS    OF    THE    PALATINE    ORGANS. 

defect  is  congenital,  though  the  aid  of  surgery  may  very  often 
be  successfully  invoked,  the  resources  of  art  will,  in  the  majority 
of  cases,  be  required.  When  the  defect  is  confined  to  the  vault 
of  the  palate,  and  consists  of  a  simple  opening  between  the 
mouth  and  nasal  cavities,  these  resources  may  always  be  success- 
fully applied,  and  even  when  the  loss  of  substance  extends  to  the 
soft  palate,  and  anterior  part  of  the  alveolar  ridge,  a  mechanical 
appliance  may  be  so  constructed,  as  to  restore,  to  some  extent, 
the  functions  dependent  upon  the  presence  and  integrity  of  the 
natural  parts. 


\ 


CHAPTER    FIRST. 

DISEASES  OF  THE  PALATE. 

In  common  with  other  parts  of  the  body,  the  palate  sometimes 
becomes  the  seat  of  various  morbid  phenomena;  but  the  occur- 
rence of  disease  here  is  generally  the  result  of  constitutional 
causes,  such  as  certain  depraved  habits  of  body.  It  is,  perhaps, 
more  frequently  induced  by  secondary  syphilis  than  by  any 
other  cause ;  and  when  so,  its  ravages  are  often  truly  deplorable. 
It  may,  however,  result  from  the  immoderate  and  protracted  use 
of  mercurial  medicine,  or  from  a  scorbutic,  cancerous,  scrofulous 
or  rickety  diathesis  of  the  general  system.  Among  the  diseases 
liable  to  attack  the  palate,  are  tumors;  caries  and  necrosis  of 
the  bones ;  ulceration  of  the  mucous  membrane ;  and  inflamma- 
tion, elongation  and  ulceration  of  the  uvula.  In  consulting 
writers  on  the  diseases  of  the  palate,  the  author  has  been  able 
to  find  but  few  who  have  written  at  much  length  on  them  :  for 
the  information  which  he  has  been  able  to  obtain  upon  the 
subject,  except  that  which  he  has  derived  from  his  own  limite<l 
observations,  he  is  principally  indebted  to  Jourdain  and  Boyer. 
The  first  of  these  authors  has  devoted,  in  the  first  volume  of  his 
Treatise  on  the  Surgical  Diseases  of  the  Mouth,  about  one 
hundred  and  forty  pages  to  the  affections  under  consideration. 

TUMORS  OF  THE  PALATE. 

Tumors  of  the  palate  are  less  frequent  in  their  occurrence 
than  morbid  growths  from  the  gums  and  alveolar  processes ; 
they  are  as  variable  in  their  appearance  and  character  as  are 
those  which  are  developed  from  other  parts  of  the  mouth. 
Sometimes  they  originate  from  the  mucous  membrane,  at  other 
times  from  the  periosteal  tissue;  sometimes  they  are  attached 
by  a  broad  base,  at  other  times  by  a  very  narrow  one.  Some 
have  a  smooth  surface,  a  whitish  and  pale  red  color,  and  a  firm 


802  CAUSES    OF    TUMORS    OF    THE    PALATE. 

flesliy  texture:  these  generally  groAv  very  slowly,  and  are  seldom 
of  a  malignant  character.  Others  have  an  uneven  surface,  are 
soft  and  vascular,  of  a  purple  color,  and  bleed  from  the  slightest 
injury. 

The  last  are  of  a  more  malignant  nature,  and  frequently  have 
a  cancerous  tendency ;  they  are  also  more  sensitive  to  the  touch 
and  more  painful.  The  first  are  seldom  attended  with  much 
pain,  and  are  less  dangerous.  In  forming  a  prognosis,  there- 
fore, it  is  necessary  to  distinguish  between  those  which  are 
simple,  and  those  which  are  of  a  malignant  or  cancerous  nature. 

Tumors  of  the  palate,  as  well  as  those  of  other  parts  of  the 
mouth,  are  always  productive  of  annoyance  and  inconvenience 
to  the  patient  in  proportion  to  their  size  and  the  malignancy  of 
their  character.  They  impede,  and,  sometimes,  destroy  the 
functions  of  mastication,  and  render  those  of  speech  and  deglu- 
tition exceedingly  difficult  and  imperfect. 

A  more  minute  description  of  tumors  of  the  palate  is  deemed 
unnecessary,  since  that  whidi  has  been  given,  in  a  preceding 
part  of  the  work,  of  the  morbid  growths  upon  the  gums  and 
alveolar  processes,  will  be  found,  for  the  most  part,  applicable  to 
those  of  the  palate.  With  regard  to  the  peculiar  pathological 
characteristics  and  nosological  classification  of  the  various  kinds 
of  tumor,  to  give  such  a  description  forms  no  part  of  the 
author's  design.  He  could  not  do  so  without  extending  the 
limits  of  this  part  of  his  work  to  too  great  a  length;  therefore, 
the  reader  is  referred,  for  more  detailed  information  upon  these 
subjects,  to  works  on  general  medicine  and  surgery. 

CAUSES. 

Concerning  the  causes  of  tumors  of  the  palate,  as  well  as 
those  of  other  parts  of  the  body,  there  exists  some  diversity  of 
opinion.  Some  authors  believe  that  they  are  attributable  in  all 
cases  to  a  peculiar  or  specific  constitutional  vice,  as  the  venereal, 
scorbutic,  cancerous,  scrofulous,  etc.;  while  others  think  they 
may  occur  in  individuals  in  whom  no  such  habit  or  vice  exists. 
That  the  character  of  the  tumor  is  determined  by  the  habit  of 
body,  or  constitutional  tendency  of  the  individual,  is,  we  believe, 
a  question  which,  at  present,  admits  of  little  doubt,  though  some 


CAUSES    OF    TUMORS    OF   THE    PALATE.  803 

exciting  cause  may  be  necessary  to  the  commencement  of  the 
disease.  Local  irritation  is  perhaps  the  immediate  or  exciting 
cause  of  the  various  morbid  growths  of  the  palate ;  but  this, 
unless  favored  by  some  specific  or  peculiar  constitutional  ten- 
dency or  cachectic  habit  of  body,  would  not  be  likely  to  give  rise 
to  them.  Thus,  while  the  former  would  seem  to  be  the  exciting 
cause,  the  specific  character  of  the  disease,  as  has  been  just 
stated,  is  evidently  determined  by  the  latter. 

Every  habit  of  body,  or  tendency  to  any  particular  form  of 
diseased  action,  may  be  regarded  as  having  a  susceptibility  to 
morbid  impressions  peculiar  to  itself.  Hence,  an  irritant  which, 
in  one  case,  might  not  be  productive  of  any  appreciable  distur- 
bance, would,  in  another,  give  rise  to  a  morbid  growth  of  a  more 
or  less  malignant  character,  according  to  the  habit  of  body,  or 
constitutional  tendency  of  tlfe  individual. 

The  irritation  produced  by  dead,  loose  and  diseased  teeth, 
ulcers  of  the  mucous  membrance  and  necrosed  bone,  are  among 
the  most  common  of  the  exciting  causes.  Some  may,  perhaps, 
be  disposed  to  question  the  agency  of  dental  irritation  in  the 
production  of  a  morbid  growth  from  the  palate,  but  the  fact  is 
too  well  established  to  admit  of  doubt.  Many  well  authenticated 
cases  are  bn  record,  which  conclusively  prove  that  diseased  teeth 
are  capable  of  exerting  a  morbid  influence  upon  these  parts.  M. 
GUYARD*  reports  the  case  of  a  woman,  forty  years  of  age,  who 
had  a  cancerous  excrescence  of  the  palate,  caused  by  an  irrita- 
tion produced  by  the  superior  incisors ;  and  numerous  examples 
of  tumor  and  other  diseases  of  the  palate,  resulting  from  the 
presence  of  diseased  teeth,  are  given  by  Jourdain  and  other 
authors,  f 

But  there  are  other  causes,  such,  for  example,  as  salivary  cal- 
culus, mucous  engorgement  of  the  maxillary  sinus,  acrid  saliva, 
and  mechanical  injuries  from  blows,  or  from  hard  substances 
taken  into  the  mouth.  Roche  and  Sanson,  in  their  Theory  and 
Practice  of  Medicine  and  Surgery,  assert  that  from  the  irrita- 
tion produced  by  syphilitic  ulcers,  carcinomatous  tumors  nearly 
always  follow. | 

®  Journal  de  Med.,  tome  xix.,  p.  3fil. 

t  Traite  des  Maladies  Chirurg.  de  la  Bouche. 

X  Nouveaus  Elements  de  Pathologie  Medieo-Cbirurgioalc,  tome  4,  p.  1011. 


s04  TREATMENT    OF    TUMORS    OF    THE    PALATE. 


TREATMENT. 

Although  tumors  of  the  palate  may  sometimes  disappear 
spontaneously  on  the  removal  of  the  exciting  cause,  the  proper 
curative  indication  consists  in  their  complete  extirpation.  When 
they  are  attached  by  a  small  base,  this  may  be  easily  effected 
with  a  pair  of  scissors  having  properly  curved  blades,  or  by 
means  of  a  ligature,  in  the  manner  directed  for  the  removal  of 
similar  tumors  upon  the  gums.  But  when  they  are  attached  by 
a  broad  base,  a  curved  bistoury  is  the  most  convenient  instru- 
ment that  can  be  employed ;  it  will  be  found  convenient  to  have 
two,  a  right  and  a  left,  so  as  to  be  able  to  cut  upon  either  side 
of  the  tumor. 

Boyer  describes  an  operation  which  he  performed  for  the 
removal  of  a  hard,  white,  indolent  tumor,  of  the  size  of  a  large 
nut,  situated  a  little  behind  the  middle  of  the  palate,  and  which 
had  occasioned  the  patient  no  other  inconvenience  than  an  up- 
pleasant  sensation  during  maistication  and  deglutition.  He  ex- 
cised the  tumor  with  a  bistoury,  curved  so  as  to  fit  exactly  the 
vault  of  the  palate,  which  he  had  made  for  the  purpose.  After 
having  removed  the  tumor,  he  destroyed  the  membrane  from 
which  it  had  originated  with  a  rasp.  The  hemorrhage  was 
suppressed  with  vinegar  and  water  and  pledgets  of  lint.  The 
wound  soon  healed,  and  at  the  expiration  of  eight  years  there 
were  no  signs  of  a  reproduction  of  the  disease.* 

In  the  removal  of  tumors  from  the  palate,  as  well  as  from 
other  parts  of  the  body,  no  portion  should  be  left ;  as,  in  this 
event,  a  reproduction  of  the  disease  would  be  likely  to  occur, 
more  especially  if  it  be  of  a  malignant  character.  The  operation 
should  be  performed,  too,  before  the  tumor  has  acquired  great 
size,  or  has  implicated,  to  any  considerable  extent,  the  neighbor- 
ing structures  in  the  diseased  action. 

^^  hen  the  morbid  production  is  of  a  cancerous  nature,  hoAvever 
perfectly  it  may  be  removed,  there  is  ahvays  great  danger  of  its 
reproduction ;  to  guard  against  this,  as  far  as  possible,  the 
Mjiplieatiou  of  the  actual  cautery  is  recommended  by  many  sur- 

*  Traito  dcs  Maladies  Chirurg.,  tome  6,  p.  449. 


TREATMENT    OF   TUMORS    OF   THE    PALATE.  805 

geons,  not  only  for  the  purpose  of  causing  exfoliation  of  a 
portion  of  the  bone,  but  also  to  arrest  the  hemorrhage  which 
generally  attends  this  class  of  operations.  Boyer,  who  says  he 
has  performed  the  operation  for  the  removal  of  4uraors  from  the 
palate  several  times,  frankly  admits  that  he  has  never  been 
successful  where  they  were  of  a  malignant  character.  But, 
notwithstanding  the  great  liability  to  reproduction  of  most 
morbid  growths,  this  does  not  always  happen,  as  is  well  at- 
tested by  many  cases  on  record  ;  from  which  it  may  be  well  to 
cite  three  or  four. 

Pierre  Guyard  reports  in  the  Journal,  to  which  reference  has 
before  been  made,  the  case  of  a  woman,  forty  years  of  age,  who  had 
a  cancerous  excrescence  of  the  palate,  of  many  years'  standing, 
which  weighed  nine  ounces.  This  excrescence  was  extirpated, 
and  the  patient  restored  to  health.  , 

The  case  of  a  man,  forty  years  of  age,  affected  with  so  large 
a  tumor  of  the  palate  that  he  could  take  no  nourishment,  except 
in  a  fluid  state,  is  reported  by  Varner.  In  this  case,  it  was  of 
a  cartilaginous  character,  interspersed  with  osseous  points,  and 
the  operation  for  its  removal  was  also  successful.* 

Jourdain  describes  the  case  of  a  man,  who  from  the  irritation 
produced  by  the  roots  of  several  decayed  teeth,  had  a  swelling 
of  the  upper  lip  and  nose,  and  a  tumor  of  the  palate  as  large 
as  a  pigeon's  egg.  A  fistula,  traversing  the  alveolar  border, 
extended  from  the  superior  lateral  incisor  to  the  first  molar  of 
the  same  side,  from  which  a  large  quantity  of  matter  was  dis- 
charged. The  teeth,  being  troublesome,  were  removed.  The 
discharge  of  matter  soon  ceased.  He  next  removed  the  tumor 
from  the  palate,  which  exposed  a  portion  of  necrosed  bone ;  this 
exfoliated  in  a  few  days,  leaving  an  opening  into  the  nose  of  the 
size  of  a  large  quill,  through  which  fluids,  taken  into  the  mouth, 
readily  passed.  By  the  application  of  caustics,  the  sides  of  the 
opening  were  caused  to  granulate,  and  in  six  weeks  it  had  en- 
tirely healed. 

The  same  author  mentions  the  case  of  a  lady,  who  had  a  tumor 
of  the  palate  caused  by  erysipelas.  The  last  named  disease 
having  extended  to  the  lips,  nose  and  vault  of  the  palate,  caused 
in  the  last  mentioned  place  ulceration,  from  the  centre  of  which 

■■  Vide  Traite  des  Maladies  Chirurg.  de  la  Bouche,  t.  1,  p.  427. 


806  CARIES  AND  NECROSIS  OF  THE  PALATE  BONES. 

irrew  a  small  fungous  tumor.  This  was  removed,  and  a  portion 
of  the  bone,  which  was  exposed,  was  found  to  be  in  a  necrosed 
and  partially  exfoliated  condition.  This  was  extracted  with  an 
excavator,  and^* under  proper  treatment,  the  patient  soon  re- 
covered. 

In  presenting  the  foregoing  cases,  the  author  has  not  thought 
it  necessary  to  give  anything  more  than  the  important  facts 
connected  with  each.  A  full  translation  of  the  reports  would 
occupy  more  space  than  he  wishes  to  devote  to  this  particular 
subject. 

It  is  seldom  that  the  operation  for  the  removal  of  tumors  of 
the  palate,  are  followed  by  results  a's  favorable  as  those  furnished 
by  the  foregoing  cases.  If  it  Avere  necessary,  many  examples 
(if  tumors  of  the  palate,  attended  with  fatal  eiFects,  might  be 
cited.  Jourdain  mentions  one  given  by  M.  Plater,  of  a  cancer- 
ous tumor  of  the  palate,  caused  by  ulceration  of  the  throat  and 
uvula. 

Both  before  and  after  the  operation,  such  general  or  consti- 
tutional treatment  as  may  be  indicated  by  the  habit  of  body 
or  vice  under  which  the  patient  may  be  laboring,  should  be 
adopted.  If  of  a  scorbutic  or  scrofulous  habit,  or  affected  with 
a  syphilitic  disease,  suitable  remedies  should  be  prescribed,  and 
when  practicable,  such  local  irritants  as  may  have  acted  as  excit- 
ing causes  should  be  removed. 


CARIES  AND  NECROSIS  OF  THE  BONES  OF  THE  PALATE,  AND 
ULCERATION  OF  THE  MUCOUS  MEMBRANE. 

The  hones  of  the  palate  sometimes  become  the  seat  of  caries 
and  necrosis,  causing  ulceration  of  the  subjacent  soft  parts,  and 
the  destruction  of  a  greater  or  less  portion  of  the  structures 
which  separate  the  cavities  of  the  mouth  and  nose.  Although 
these  effects  are  of  more  frequent  occurrence  than  tumors,  they 
are  less  dangerous  in  their  consequences.  Commencing  with  in- 
flammation and  suppuration  of  the  periosteal  tissue,  caries,  and 
necrosis  of  the  bones,  accompanied  by  ulceration  of  the  invest- 
ing mucous  membrane,  supervene,  and  ultimately  exfoliation 
takes  place,  when  an  opening  of  greater  or  less  size,  between  the 
buccal  and  nasal  cavities,  is  established. 


CARIES  AND  NECROSIS  OF  THE  PALATE  BONES.  807 

During  the  progress  of  the  disease,  fetid  sanies  is  continually 
discharged  from  one  or  more  fistulous  openings,  into  the  mouth, 
and  sometimes  into  the  cavities  of  the  nose,  rendering  the  con- 
dition of  the  unhappy  sufferer  exceedingly  loathsome  and  dis- 
tressing. The  progress  of  the  disease  is  often  slow,  continuing, 
not  unfrequently,  for  weeks,  months,  and  in  some  cases  even 
years,  destroying  all  the  pleasures  of  life,  and  rendering  ex- 
istence itself  a  hurden.  A  case  of  this  kind  was  recently 
introduced  into  the  infirmary  of  the  Baltimore  College  of  Dental 
Surgery,  which  will  be  noticed  at  some  length,  when  the  author 
comes  to  treat  of  the  means  employed  for  remedying  defects  of 
the  palatine  organs. 

Dr.  Brown,  of  Missouri,  describes  a  very  interesting  case  of 
the  destruction  of  a  large  portion  of  the  palate  plates  of  the  su- 
perior maxillary  and  palate  bones,  accompanied  by  the  loss  of 
the  left  lateral  and  central  incisors.* 

The  ravages  of  caries  and  ulceration  of  the  palate  are  some- 
times so  great  that  the  palatine  bones,  the  palate  plates  of 
the  superior  maxilla,  the  vomer,  turbinated  and  nasal  bones, 
together  with  the  velum  and  uvula,  are  entirely  destroyed,  but 
when  thus  extensive,  they  are  seldom  arrested,  except  with  the 
life  of  the  patient. 

The  ulcerative  process  of  the  soft  parts,  when  resulting  from 
caries  of  the  bones,  frequently  extends  to  the  pituitary  mem- 
brane, lining  the  floor  of  the  nasal  fossae.  A  case  of  this  kind, 
and  to  which  the  author  will  hereafter  have  occasion  to  refer, 
is  related  by  Jourdain. 

But  ulceration  of  the  mucous  membrane,  lining  the  vault  of 
the  palate,  often  occurs  while  the  bones  are  in  a  healthy  con- 
dition. It  is  frequently  caused  by  inflammation  and  ulceration 
of  the  velum  and  uvula,  whether  resulting  as  an  effect  of  second- 
ary syphilis  or  from  malignarit  ozena  produced  by  other  causes. 
But,  whatever  the  producing  cause  of  the  ulceration,  it  may 
ultimately  give  rise  to  caries  and  necrosis  of  the  bones. 

*  Vide  Am.  Jour.  Dent.  Sci.  vol.  6,  p.  2;:!6. 


SOH  TREATMENT    OF    CARIES,    ETC.,    OF    PALATE    BONES. 


CAUSES. 

Caries,  necrosis  and  ulceration  of  the  palate,  as  in  the  case 
of  tumors,  result  from  local  irritation  and  certain  habits  of  body, 
or  constitutional  vices.  The  immediate  or  exciting  cause  is  local 
irritation  ;  but  the  extent  of  the  effects  resulting  from  such  irri- 
tation is,  as  we  have  before  stated,  in  proportion  to  the  suscepti- 
bility of  the  body  to  morbid  impressions.  The  local  irritations 
are  the  same  as  those  which  have  been  already  mentioned, 
namely :  dead  and  loose  teeth,  roots  of  teeth,  salivary  calculus, 
mechanical  injuries,  acrid  humors,  etc.  The  case  of  a  lady  of 
irreproachable  character  is  related  by  Jourdain,  in  whom  a 
scratch  on  the  palate  with  a  fish-bone  caused  a  tumor,  which 
suppurated  and  degenerated  into  an  ulcer,  with  hard,  elevated 
edges  and  a  fungus  in  the  middle.*  A  case,  in  which  similar 
effects  were  produced,  and  by  the  same  cause,  was  mentioned 
to  the  author,  in  1849,  by  a  dentist  of  Baltimore.  Local  irrita- 
tion, unquestionably,  has  much  more  to  do  in  the  production  of 
the  diseases  under  consideration  than  many  seem  to  imagine  or 
are  wdling  to  admit.  Most  writers  are  of  the  opinion  that  they 
are  wholly  caused  by  some  constitutional  vice,  and  nearly  always 
by  the  venereal ;  but  that  this  opinion,  to  some  extent  at  least, 
is  erroneous,  will  be  fully  proven  by  certain  facts  which  will  be 
presented  when  we  come  to  speak  of  the  treatment  of  these 
affections. 

TREATMENT. 

In  the  treatment  of  caries  of  the  bones  of  the  palate,  it  is 
important  to  ascertain  if  the  patient  be  laboring  under  any  con- 
stitutional vice  which  may  have  contributed  to  the  disease ;  also, 
what  were  the  local  irritants  concerned  in  giving  rise  to  it.  If 
the  inflammation  from  which  it  resulted  was  caused  by  mechani- 
cal irritation,  the  irritants  should  at  once  be  removed.  If  de- 
cayed, dead  or  loose  teeth  be  suspected  as  having  had  any 
agency  in  its  production,  they  should  be  immediately  extracted; 
but  so  long  as  any  portion  of  decayed  or  necrosed  bone  remains, 

*  Traitt-  des  Malad.  Chirurg.  de  la  Boucbe,  torn.  1,  p.  407. 


TREATMENT  OF  CARIES,  ETC,  OF  PALATE  BONES.    80H 

it  is  needless  to  say,  the  ulcerations  or  fistulous  openings  in  the 
soft  parts  cannot  be  healed.  These,  as  soon  as  they  have  be- 
come sufficiently  exfoliated,  should  be  detached  and  removed;  in 
doing  which  it  may  be  necessary  to  increase  the  size  of  the  ex- 
ternal opening.  During  the  process  of  exfoliation,  the  mouth 
should  be  frequently  gargled  with  astringent  and  detergent  lo- 
tions, for  the  purpose  of  neutralizing  the  odor  of  the  offensive 
matter  which  is  continually  discharged. 

Suitable  constitutional  remedies  should,  at  the  same  time,  be 
prescribed.  As  in  the  case  of  tumors,  if  the  patient  be  labor- 
ing under  a  scorbutic,  scrofulous  or  venereal  diathesis,  the  indi- 
cations for  the  cure  of  these  should  be  properly  fulfilled.  But. 
before  instituting  any  general  treatment,  we  should  be  well  as- 
sured that  our  diagnosis  is  correct.  A  venereal  vice  is  some- 
times suspected  when  none  exists,  as  is  shown  by  the  following 
brief  summary  of  the  history  of  a  case  related  by  Jourdain: 

The  subject  of  this  case  was  a  man  who  had  a  swelling  which 
occupied  the  whole  of  the  left  side  of  the  vault  of  the  palate, 
from  which  there  had  been  a  fistulous  opening  for  a  long  time. 
The  edges  were  hard  and  indurated.  Venereal  vice  was  sus- 
pected as  the  cause,  and  for  this  disease  treatment  was  proposed : 
but,  the  patient  not  being  willing  to  submit,  Jourdain  was  con- 
sulted, w^ho  advised  the  removal  of  the  roots  of  three  or  four 
teeth  in  the  vicinity  of  the  disease.  This  operation  was  per- 
formed, and  the  fistulous  opening  at  the  same  time  enlarged, 
when  the  bone  was  found  to  be  in  a  carious  condition;  but  with 
little  other  treatment,  a  complete  cure  was  soon  effected. 

That  the  effects  resulting  from  dental  irritation  may  extend  to 
the  palate,  is  shown  by  the  following  particulars,  taken  from  the 
history  of  a  case  given  by  the  same  author :  A  man  called  upon 
Jourdain  for  advice  in  relation  to  a  tumor  on  the  vault  of  the 
palate.  Upon  examination,  a  sensible  fluctuation  was  perceived. 
On  being  pressed,  fetid  pus  escaped  from  a  small  fistulous  open- 
ing between  the  right  lateral  incisor  and  canine  tooth,  and  also 
from  the  socket  of  the  second  bicuspid,  which  had  been  extracted 
a  short  time  before.  The  alveolar  socket  of  this  tooth  commu- 
nicated with  the  first-mentioned  fistula  and  the  disease  in  the 
palate.  Notwithstanding  these  two  outlets  for  the  escape  of  the 
matter,  it  accumulated  in  the  palatine  tumor.  Various  means 
52 


)^10    TREATMENT  OF  CARIES,  ETC.,  OF  PALATE  BONES. 

were  resorted  to  for  the  cure  of  the  disease,  but  without  success. 
The  nasal  fossae,  by  the  accumulation  of  matter,  were  partially 
closed,  the  alveoli  of  the  lateral  incisor,  cuspid  and  first  bicuspid 
became  necrosed,  the  teeth  loosened  and  were  extracted.  The 
alveoli  exfoliated,  the  tumor  of  the  palate  was  opened,  when  the 
bones  of  the  palate  and  alveolar  ridge  were  found  in  a  necrosed 
and  partially  exfoliated  state.  These  were  removed  without 
much  difficulty,  leaving  an  opening  through  to  the  pituitary 
membrane  which  lined  the  floor  of  the  nasal  fossae.  These  por- 
tions of  bone  having  been  removed,  the  parts  soon  healed. 

That  the  caries  in  the  two  last  cases  was  caused  by  dental  irri- 
tation, there  can  be  no  question,  and  that  it  often  results  from 
this  cause,  we  have  not  the  least  doubt.  In  the  last  case,  it  is 
probable  that  the  second  bicuspid  of  the  affected  side  was  not 
extracted  until  an  abscess  had  formed  at  the  extremity  of  its 
root.  The  matter,  instead  of  escaping  externally,  had  effected 
a  passage  through  the  inner  wall  of  the  alveolus,  and  thence 
between  the  palate  plate  of  the  superior  maxilla  and  mucous 
membrane  to  near  the  median  line,  where  it  had  accumulated, 
produced  the  tumor  mentioned  by  Jourdain,  and  ultimately  made 
a  passage  for  its  escape  between  the  lateral  incisor  and  cuspid. 
Several  cases,  followed  by  very  similar  effects,  have  fallen  unc 
the  immediate  observation  of  the  author.  But  when  associat 
with  a  cachectic  habit  of  body  or  venereal  vice,  the  effect^ 
more  destructive,  and,  in  this  case,  local  treatment 
suffice. 

Ulceration  of  the  palatine  mucous  membrane  may  occi 
out  caries  of  the  subjacent  bone ;  it  may  result  as  a  consc 
of  ulceration  or  other  disease  of  the  velum  or  uvula,  oi 
some  mechanical  injury  inflicted  upon  the  parts.  When 
a  simple  nature,  cooling  and  astringent  gargles,  preceded 
mild  aperients,  will  generally  suffice  for  its  cure.  If  dependent 
upon  a  specific  constitutional  tendency  or  vice,  appropriate  gen- 
eral remedies  should  be  employed.  But  with  regard  to  the 
treatment  of  ulcers  of  the  palate,  we  shall  have  occasion  to 
speak  when  we  come  to  treat  of  the  diseases  of  the  velum  and 
uvula. 


INFLAMMATION    OF    THE    VELUM    AND    UVULA.  811 


INFLAMMATION  AND  ULCERATION  OF  THE  VELUM  AND  UVULA. 

The  velum  palati  and  uvula  sometimes  become  the  seat  of  in- 
flammation, accompanied  by  pain,  increased  redness,  difficulty  of 
deglutition  and  articulation.  Most  frequently  it  terminates  in 
resolution,  sometimes  in  ulceration,  and  at  other  times  in  gan- 
grene. When  resolution  is  the  termination,  it  gradually  sub- 
sides, after  having  continued  for  a  greater  or  less  length  of  time ; 
when  by  ulceration,  one  or  more  Avhite  or  ash  colored  spots  ap- 
pear upon  the  velum  and  uvula,  after  it  has  continued  for  a 
certain  period;  and  when  by  gangrene,  the  part,  after  having 
assumed  a  dark  purple  or  almost  black  color,  sloughs.  Fortu- 
nately, this  latter  termination  rarely  happens. 

As  a  consequence  of  inflammation,  the  uvula  sometimes  be- 
comes tumefied  and  elongated;  at  other  times  it  becomes  elon- 
gated when  there  is  no  apparent  tumefaction.  In  the  latter 
case,  it  is  familiarly  termed  a  "falling  of  the  palate."  Most 
frequently,  when  it  is  elongated,  its  thickness  is  at  the  same 
time  increased.  In  this  case  there  is  an  increase  of  redness; 
but  when  there  is  elongation,  without  an  increase  of  size,  result- 
ing simply  from  relaxation  of  the  part,  its  color,  instead  of  being 
heightened,  is  often  diminished,  presenting  a  whitish  or  semi- 
transparent  appearance.  This  description  of  elongation  is 
termed  serous  tumefaction  of  the  uvula.  It  is  seldom  accompa- 
nied by  pain. 

When  the  uvula  becomes  so  much  elongated  as  to  rest  upon 
the  tongue,  it  causes  irritation,  diflBcult  deglutition,  attended 
often  by  a  sense  of  suffocation,  the  frequent  expulsion  of  mucus 
from  the  throat,  and  sometimes  a  disagreeable  cough. 

Ulcers  of  various  kinds  sometimes  attack  these  parts,  though 
they  are  less  subject  to  them  than  are  the  other  parts  of  the 
mouth,  fauces  and  tonsils.  Sometimes  the  ulcers  are  of  a  simple 
nature,  at  other  times  they  are  aphthous,  scrofulous,  scorbutic, 
venereal  or  cancerous,  according  to  the  specific  poison  or  diathe- 
sis which  has  given  rise  to  them.  When  the  ulcer  is  not  depen- 
dent upon  constitutional  causes,  it  is  termed  a  simple  ulcer,  and 
is  nothing  more  than  a  granulating  sore  which  secretes  healthy 
purulent  matter. 


812  INFLAMMATION    OF    THE    VELUM    AND    UVULA. 

Aphthous  ulcers  at  first  appear  in  the  form  of  whitish  or  trans- 
parent vesicles,  which  break,  and  are  ultimately  transformed  into 
ulcers,  either  surrounded  by  a  slightly  elevated  edge  of  a  reddish 
color,  or  spread  and  unite  with  each  other.  The  former  are 
termed  disa-cte,  and  the  latter  conjluent,  aphthae.  But  ulcers 
of  this  kind  generally  appear  in  other  parts  of  the  mouth  and 
fauces  before  they  attack  the  velum  and  uvula  of  the  palate. 

The  velum  and  uvula  are,  perhaps,  more  subject  to  venereal, 
than  to  any  other  kind  of  ulcers.  The  symptoms  of  these  are, 
sometimes,  very  similar  to  ulcers  which  result  from  some  other 
specific  constitutional  vice,  and  their  character  can  only  be  posi- 
tively determined  by  ascertaining  all  the  other  circumstances 
connected  with  the  history  of  the  case.  They  are  generally  pre- 
ceded by  ulceration  of  the  throat,  dull  heavy  pain,  especially  at 
night,  increased  redness  of  the  parts,  swelling  of  the  uvula,  and 
difficult  deglutition.  The  parts  usually  have  a  whitish,  dirty 
gray,  or  ash-colored  appearance,  with  slightly  elevated  and 
irregular  margins,  and  secrete  thin  ichorous  matter  of  a  very 
fetid  odor.  The  surrounding  parts  are  preternaturally  red,  and 
sometimes  present  an  almost  purple  appearance.  At  other  times 
the  ulcers  appear  in  the  form  of  aphthous  spots,  followed  by 
sloughing  of  the  surrounding  parts.  Sometimes  the  ulcers  attack 
the  posterior  side  of  the  velum  and  uvula  first,  where  they  com- 
mit extensive  ravages  before  they  appear  anteriorly.  From  these 
parts  they  often  extend  to  the  vault  of  the  palate,  but  more  fre- 
quently, when  they  appear  here,  the  periosteal  tissue  and  bones 
are  diseased  before  ulceration  shows  itself  in  the  mucous  mem- 
brane. 

The  velum  and  uvula  are  sometimes  the  seat  of  bad  conditioned 
ulcers,  such  as  the  cancerous,  scrofulous,  etc.  Sometimes  they 
arise  as  a  consequence  of  protracted  and  immoderate  use  of 
mercury.  When  they  result  from  this  cause,  they  are  preceded 
by  a  copperish  taste  in  the  mouth  ;  increased  flow  and  viscidity 
of  the  saliva  ;  tumefaction  and  increased  sensibility  of  the  gums, 
looseness  of  the  teeth  ;  a  peculiar,  disagreeable  odor  of  the 
breath,  general  debility  and  emaciation,  and  sometimes  diarrhoea. 
Ulceration  attacks  the  gums,  edges  of  the  tongue,  the  mucous 
membrane  about  the  angles  of  the  jaws,  the  inner  surface  of  the 
cheeks  and  throat,  before  it  does  the  velum  and  uvula. 


TREATMENT  OF  INFLAMMATION  OF  VELUM  AND  UVULA.     813 

CAUSES. 
Inflammation  of  the  A^elum  and  uvula  most  frequently  result 
from  irregular  exposure  to  cold  and  moisture,  though  it  may 
sometimes  be  produced  by  sopae  local  irritation,  as  mechanical 
injury,  acidity  of  the  gastric  and  buccal  fluids.  Ulceration  of 
the  parts  may  result  from  the  same  causes,  the  character  which 
the  ulcer  assumes  being  determined  by  the  habit  of  body,  or 
peculiar  diathesis  of  the  general  system.  Elongation  of  the 
uvula  is  caused  either  by  inflammation  and  general  enlargement, 
by  relaxation  of  the  parts,  or  by  serous  infiltration  of  its  apex. 

TREATMENT. 

For  simple  inflammation  of  the  velum  and  uvula,  unaccom- 
panied by  fever  or  other  general  constitutional  effects,  little  else 
will  be  required  than  gargling  the  throat  with  an  infusion  of 
capsicum,  sweetened  with  honey.  When  the  inflammation  is 
severe,  and  the  vessels  have  the  appearance  of  being  distended, 
advantage  may  be  derived  from  scarifying  the  parts. 

But  when  the  uvula  is  so  much  elongated  as  to  rest  upon  the 
tono;ue,  and  cause  a  sensation  of  suffocation  or  a  troublesome 
cough,  if  it  does  not  yield  to  exciting  and  astringent  gargles,  it 
may  become  advisable  to  remove  a  portion  of  it. 

For  this  operation,  though  an  exceedingly  simple  one,  a 
variety  of  instruments  have  been  invented.  The  best,  however, 
which  the  author  has  seen,  is  the  one  invented  by  Dr.  Hullihen. 

Fig.  291. 


This  instrument,  although  very  simple  in  its  construction,  is  an 
exceedingly  useful  one,  for,  at  the  same  time  that  it  cuts  the 
uvula,  it  secures  the  excised  extremity,  and  prevents  it  from 
fallin^T.     The  construction  of  this  instrument,  and  the  manner 


bl4     TREATMENT  OF  INFLAMMATION  OF  VELUM  AND  UVULA. 

(.f  using  it  are  so  very  simple,  that  the  accompanying  engraving 
will  supersede  the  necessity  of  any  description.* 

For  a  simple  ulcer  of  the  velum  or  uvula,  no  other  treatment  will 
be  required  than  to  gargle  the  throat  occasionally  with  some  gently 
stimulatin<yand  astringent  lotion;  the  one  recommended  for  inflam- 
mation of  these  parts  may  generally  be  employed  with  advantage. 

In  the  treatment  of  venereal  or  syphilitic  ulcers  of  the  velum  and 
uvula,  little  advantage  will  be  obtained  from  local  remedies.  They 
can  only  be  cured  by  appropriate  constitutional  treatment,  such  as 
is  prescribed  in  works  on  general  medicine  and  surgery.  To  these, 
therefore,  the  reader  is  referred  for  information  upon  this  subject. 

In  cases  of  mercurial  ulcers,  it  is  desirable  that  two  or  three 
liquid  evacuations  from  the  bowels  should  be  procured  daily. 
For  this  purpose,  sulphate  of  magnesia  or  sulphur  may  be  ad- 
ministered night  and  morning.  The  mouth  should,  at  the  same 
time,  be  gargled  six  or  eight  times  a  day  with  some  gently 
astringent  lotion.  A  weak  solution  of  the  sulphate  of  zinc,  or 
alum  sweetened  with  honey,  may  sometimes  be  advantageously 
employed,  but  more  benefit,  perhaps,  will  be  derived  from  the 
use  of  the  chlorinated  solution  of  soda.  When  the  pain  is  so 
severe  as  to  prevent  rest,  opium  should  be  prescribed.  The  diet 
of  the  patient,  for  the  most  part,  should  consist  of  farinaceous 
substances,  and  after  the  ulcers  have  begun  to  heal,  milk,  light 
soups,  etc,  may  be  recommended. 

In  the  treatment  of  scirrhous  and  other  ill-conditioned  ulcers 
of  the  velum  and  uvula,  dependent  upon  a  cachectic  habit  of 
body,  it  is  necessary  that  the  constitutional  indications  should  be 
properly  fulfilled,  and  that  tlie  vitiated  action  of  the  disease 
should  be  changed  by  the  application  of  local  irritants,  such  as 
caustics.  The  application  of  the  actual  cautery  has  been  found 
more  efficient  in  changing  tlie  condition  of  ulcers  of  this  sort, 
and  exciting  a  healthy  action  in  them,  than  any  other  means 
which  have  been  employed. 

For  cancerous  ulcers,  it  has  been  found  necessary  to  remove 
a  greater  or  less  ])ortion  of  the  velum  and  uvula,  and  even  this 
operation  has  seldom  proved  successful ;  for  the  disease,  after  a 
greater  or  less  length  of  time,  reappears  in  situ  or  in  some  of 
the  neighboring  parts. 

*  An  engraving  and  description  of  Dr.  HuUihen's  uvula  scissors  are  contained  in 
voL  7,  No.  i,  of  Am.  Jour,  and  Lib.  of  Dental  Science. 


CHAPTER    SECOND. 
DEFECTS  OF  THE  PALATINE  ORGANS. 

The  nature  and  extent  of  the  defects  of  the  palatine  organs 
are  various.  They  sometimes  consist  of  a  simple  perforation  of 
the  vault  of  the  palate ;  this  may.  be  in  the  centre,  or  on  either 
side  of  the  median  line.  At  other  times,  the  loss  of  substance 
extends  to  the  entire  vault  and  velum.  Nor  is  the  loss  always 
confined  to  these  parts ;  it  sometimes  extends  to  the  anterior 
part  of  the  alveolar  border,  and  a  portion  of  the  upper  lip,  con- 
stituting what  is  usually  termed  hare-lip. 

The  defects  of  the  palatine  organs,  as  we  have  before  stated, 
may  be  divided  into  accidental  and  congenital.  The  first  result- 
ing from  accidental  causes,  the  second  from  malformation  of  the 
parts. 

ACCIDENTAL  DEFECTS. 

Accidental  lesions  of  the  palatine  organs  are  divided  by  M. 
Delabarre  into  three  species.  The  first  consists  in  perforations 
of  the  vault  of  the  palate ;  the  second,  in  perforations  of  the 
velum,  and  the  third,  in  the  destruction  of  the  entire  vault  of  the 
palate,  or  of  a  great  portion  of  it.  To  this  last  might  also  be 
added  the  destruction  of  the  whole,  or  a  large  portion  of  the 
velum,  as  well  as  of  the  vomer,  part  of  the  alveolar  border  and 
turbinated  bones.* 

It  has  also  been  remarked,  that  lesions  of  the  palate  and 
velum,  resulting  from  disease,  differ  from  congenital  defects. 
The  first  most  frequently  perforate  the  side  of  the  palatine  vault, 
and  communicate  with  only  one  nostril ;  whereas,  the  latter,  as 
will  presently  be  seen,  occupy  the  centre  of  the  arch,  and  pene- 
trate both  of  the  nasal  cavities. 

The  causes  of  accidental  lesions  or  defects  of  the  palate  and 
velum,  have  already  been  treated  of;  the  manner  of  remedying 
them  will  hereafter  be  described. 

*  Traite  de  I'Art  Meclumique  du  Cliirurgien  Dcntiste.  t.  1,  p.  294. 


816  DEFECTS    OF    THE    PALATINE    ORGANS. 


CONGENITAL  DEFECTS. 

Congenital  defects  of  the  palate  occupy  the  median  line  or 
]»alatine  raphe,  and  consist  in  the  division  to  a  greater  or  less 
extent  of  the  osseous  and  soft  textures.  This  division  is  some- 
time? confined  to  the  vault  of  the  palate ;  at  other  times  the 
velum,  the  anterior  part  of  the  alveolar  arch  and  the  upper  lip 
participate.  It  forms  a  communication  with  both  nostrils ;  and 
when  the  malformation  extends  to  the  alveolar  border  and  upper 
lip,  which  is  divided  vertically  in  one,  and  sometimes  in  two 
places,  it  gives  to  the  mouth  a  most  disagreeable  aspect.  But 
hare-lip  is  sometimes  met  with  when  there  is  no  imperfection  of 
the  osseous  structures ;  and  imperfections  are  often  met  with  in 
these  latter  when  the  lip  is  perfect.  In  some  cases  the  cleft  or 
fissure  is  more  than  three-fourths  of  an  inch  wide  throughout  the 
whole  extent  of  the  palate  and  velum,  accompanied  by  absence 
of  the  whole  of  that  portion  of  the  alveolar  border  which  should 
be  occupied  by  the  four  incisors  ;  at  other  times  the  alveolar  arch 
is  divided  in  two  places,  leaving  a  portion  between  the  lateral 
and  central  incisors,  or  one  lateral  and  one  central,  which  pro- 
ject more  or  less,  and  thus  very  greatly  increase  the  deformity. 
Although  a  double  hare-lip,  with  two  divisions  of  the  alveolar 
border,  is  seldom  met  with  without  some  defect  of  the  palatine 
organs,  such  cases  do  occasionally  occur.  Dr.  Marion  Simms, 
a  skillful  and  distinguished  surgeon,  formerly  of  Montgomery, 
Ala.,  describes  a  most  interesting  case  of  this  kind,  in  vol.  5th, 
page  51,  of  the  American  Journal  of  Dental  Science. 

Congenital  defects  of  the  palate  are  sometimes  accompanied 
by  more  or  less  deformity  of  the  sides  of  the  alveolar  arch,  and 
of  the  teeth.  Sometimes  the  sides  of  the  alveolar  ridge  are 
forced  too  far  apart,  and  at  other  times  they  are  too  near  each 
other,  while  the  teeth  are  either  too  large  or  too  small,  with 
inijierfectly  developed  roots,  and  generally  of  a  soft  texture. 

Want  of  coaptation,  resulting  from  defect  of  formation  in  the 
palatine  plates  of  the  maxillary  and  palate  bones,  are  the  cause 
of  congenital  deficiencies  of  the  parts  in  question.  In  the  human 
embryo  of  about  the  third  week,  the  development  of  the  face  is 


DEFECTS  OF  THE  PALATINE  ORGANS.  817 

clearly  in  progress.  Five  tubercles  bud  out  from  the  front  of 
the  cephalic  mass,  of  ^yhich  the  middle  one  which  is  double,  is 
directed  vertically  downward,  and  bears  the  appellation,  in- 
cisive tubercles,  because  the  intermaxillary  bones,  destined  to 
bear  the  superior  incisor  teeth  exclusively,  are  developed  in  it. 
On  either  side  is  the  tubercle  or  rudiment  of  an  upper  maxillary 
bone,  which  is  separated  from  its  fellow  by  a  wide  interval,  and 
from  the  neighboring  incisive  process  by  a  fissure.  The  fourth 
and  fifth  tubercles,  also  separated  in  front,  form  by  their  subse- 
quent union  in  the  median  line  the  inferior  maxillary  bone.  At 
the  same  period  the  palate  begins  to  be  formed  by  the  approach 
toward  the  median  line  of  two  horizontal  plates  or  processes, 
springing  from  the  maxillary  process  on  either  side. 

If   now,    development   proceed    regular!}'  and  normally,  the 
palate  processes  of  the  superior  maxilla 
meet  in  the  median  line  and  unite  with 
the   blended   intermaxillary  tubercles, 
while  the  vomer  grows   downward    to 
meet  the  palate  processes  in  their  line 
of  union.     The   upper  jaw,   after   the 
accomplishment  of  the  changes,  is  com- 
plete, and  the  formation  of  the  lip  and 
primary  dental  groove   follow  in  due 
course.    But  it  sometimes  happens  that 
the  superior  maxillary  and  intermaxil- 
lary processes  fail  to  unite  with  each  other,  whence  we  have  the 
malformation  known  as  hare-lip,  or  the  palate  plates  are  arrested 
in  their  growth,  and  permanent  fissure  of  the  palate  is  the  result. 
Consequently,  the  fissure  of  single  hare-lip  is  never  exactly  in 
the  median  line,  but   on  one  edge  of  the  intermaxillary  bone  ; 
whereas,  in  double   hare-lip,  a  fissure  exists  on  each  side  of  this 
bone,  into  which  the  four  incisor  teeth  are  implanted. 

Fissure  of  the  palate  is  usually  a  little  lateral  and  not  median, 
as  it  results  from  a  deficiency  of  one  or  other  of  the  palate  plates 
of  the  upper  maxillary  bone  ;  and  it  is  frequently  associated  with 
hare-lip  and  fissure  of  the  upper  jaw. 

The  tubercles,  or  formative  processes  of  the  lower  jaw,  advance 
and  meet  in  the  median  line,  while  the  upper  maxillary  pro- 
cesses are  still  separate.     In  man  they  are  consolidated   into  a 


818  DEFECTS   OF   THE    PALATINE    ORGANS. 

sint'lc  piece:  but  they  remain  permanently  divided  in  many  of 
the  lower  animals  by  a  median  suture.* 

Thus  it  is  seen,  that  the  defects  of  the  palatine  organs  which 
result  from  malformation,  present  as  much  diversity  of  character 
as  do  those  which  are  produced  by  disease,  or  other  accidental 
causes.  Mr.  Stearns,  of  London,  in  a  very  able  and  highly  in- 
teresting paper,  published  in  the  London  Lancet,  on  "  Congenital 
Fissure  of  the  Palate,"  in  noticing  their  various  anatomical 
peculiarities  divides  them  into  three  classes. 

The  first  class  embraces  all  the  cases  in  which  the  fissure  ex- 
tends through  the  velum,  palate  and  maxillary  bones,  to  the 
alveolar  border  and,  sometimes,  through  the  whole  extent  of  the 
median  symphysis.  This  form  of  fissure  is  the  most  extensive, 
and  justly  regarded  as  the  worst,  and  is  usually  complicated 
with  hare-lip. 

In  tlie  second  class,  the  bones  of  the  palate  are  appai'ently 
entire,  though  the  concavity  of  the  arch  may  be  somewhat  greater 
than  usual,  and  the  fissure  may  extend  a  short  distance  into  their 
"posterior  margin."  The  lesion,  in  this  case,  is  almost  wholly 
confined  to  the  velum  palati. 

The  third  class  embraces  those  cases  in  which  the  fissure  is 
confined  to  the  soft  parts,  extending,  perhaps,  only  a  short  dis- 
tance up  into  the  uvula.  This  form  of  fissure  is,  probably,  less 
frequently  met  with  than  either  of  the  preceding. 

FUNCTIONAL  DISTURBANCES,  RESULTING  FROM  DEFECTS  OF 
THE  PALATINE  ORGANS. 

The  principal  effects  resulting  from  an  absence  of  a  portion  of 
the  palatine  organs,  are,  as  we  have  before  stated,  an  impair- 
ment of  the  functions  of  mastication,  deglutition  and  speech. 
Distinct  utterance  is  sometimes  wlioUy  destroyed,  and  mastica- 
tion and  deglutition  are  often  so  much  embarrassed  as  to  be 
performed  only  with  great  difficulty.  These  efi'ects  are  always 
in  proportion  to  the  extent  of  the  separation  or  deficiency  of  the 
parts.  We  shall  first  speak  of  those  modifications  of  the  functions 
of  mastication  and  deglutition  which  result  from  absence  of  a 
portion  of  the  palatine  organs. 

*■  Vide  Dalton's  Physiology. 


DEFECTS    OF    THE    PALATINE    ORGANS.  819 

The  simple  act  of  triturating  the  food  may  not  be  materially 
impaired  by  the  absence  of  a  portion,  however  extensive,  of  the 
palatine  organs,  unless  the  natural  relations  of  the  teeth  of  the 
upper  and  lower  jaws  are  changed ;  still  the  process  is  more  or 
less  interfered  with,  as  substances  taken  into  the  mouth  cannot 
be  so  readily  managed,  as  when  the  parts  are  in  their  natural 
state.  They  are  constantly  escaping  from  the  control  of  the 
tongue,  and  passing  up  into  the  cavity  of  the  nose. 

In  cases  of  congenital  defects  of  the  palate  and  velum,  it  is 
difficult  to  conceive  how,  in  infancy,  infants  manage  to  obtain 
from  the  breast  of  the  mother  or  nurse,  the  food  necessary  for 
their  subsistence  ;  yet,  even  when  the  anterior  part  of  the  alveolar 
border,  and  a  part  of  the  upper  lip  are  wanting,  the  suggestions 
of  natural  instinct  enable  them  by  a  peculiar  management  of 
tongue  and  lips  to  do  it.  The  expedient  resorted  to  for  effecting 
this  process  is  curious.  The  nipple,  instead  of  being  seized  be- 
tween the  tongue,  upper  lip  and  gum,  is  taken  between  its  lower 
surface,  and  the  under  lip  and  gum,  and  in  this  way  it  manages 
to  extract  the  nourishment  necessary  for  subsistence  and  growth. 
The  tongue,  as  is  remarked  by  M.  Delabarre,  is  thus  made  to 
close  the  opening  in  the  palate,  and  perform  the  office  of  an 
obturator.  By  contracting  the  lip  and  depressing  the  tongue, 
the  milk  is  drawn  from  the  breast  of  the  mother  or  nurse.  At 
this  young  and  tender  age,  the  child  is  not  conscious  of  the  im- 
perfection of  its  palate ;  it  is  not,  as  is  remarked  by  the  author 
just  mentioned,  until  the  period  arrives  when  it  should  begin  to 
make  its  wants  known  by  words,  that  it  feels  the  importance  of 
the  functions  of  speech  and  begins  to  realize  the  misfortune  with 
which  it  is  afflicted. 

"But  as  the  child  arrives  at  this  period,"  says  M.  Delabarre, 
"  the  mechanism  of  sucking  is  perfected,  and  ultimately  applied 
to  the  mastication  of  solid,  aliments.  The  food,  when  chewed, 
is  conveyed  between  the  tongue  and  movable  floor,  which  serves 
for  a  point  d'appui,  and  thence  it  is  brought  back  between  the 
teeth.  Thus  it  is,  that  the  complicated  operation  of  mastication 
and  deglutition  is  performed  without  the  alimentary  morsel  get- 
ting into  the  nose;  or,  if  this  does  sometimes  happen,  it  is  the 
result  of  accident.  But  in  cases  of  accidental  lesion  of  the  palate, 
the  individual  has  not  the  advantage  of  this  training  of  the  parts 


820  DEFECTS    OF    THE    PALATINE    ORGANS. 

durinf'  earlv  infancy.  Those  who  are  afflicted  with  accidental 
lesions,  no  matter  what  may  be  their  position  and  extent,  having 
acquired  the  habit  of  eating,  by  placing  the  aliment  upon  and  not 
under  the  tongue,  can  take  no  nourishment,  without  a  part  of  it 
getting  into  the  nose."  When  to  this  inconvenience  is  added  a 
change  in  the  natural  relation  of  the  teeth  of  the  two  jaws,  mas- 
tication is  rendered  still  more  diflBcult  and  embarrassing.  When 
this  is  the  case,  the  tubercles  of  the  teeth  of  one  jaw,  instead  of 
being  received  into  the  depressions  of  those  of  the  other,  strike 
upon  their  protuberances,  and  cannot  be  made  to  triturate  the 
food  in  as  thorough  and  perfect  a  manner  as  is  required  for  healthy 
and  easy  digestion.  Thus,  not  only  is  the  process  of  mastication 
rendered  imperfect,  but  it  is  also  more  tedious. 

The  process  of  deglutition  itself,  so  long  as  the  velum  and 
uvula  are  perfect,  is  not  materially  affected  by  a  perforation 
simply  of  the  vault  of  the  palate,  although  much  difficulty  may 
be  experienced  in  conveying  alimentary  and  fluid  substances  to 
the  fauces  and  pharynx.  But  when  this  curtain  is  cleft,  or  is 
partially  or  wholly  wanting,  deglutition  is  rendered  very  difficult, 
for,  by  the  contraction  of  the  muscles  of  the  pharynx,  part  of 
the  food  is  forced  up  into  the  nose.  The  reason  of  this  will 
appear  obvious,  when  we  take  into  consideration  the  form  and 
function  of  this  movable  appendage.  When  its  muscles  are  re- 
laxed, it  forms  a  slightly  concave  curtain  ;  but  in  the  act  of  de- 
glutition, the  muscles  contract,  raise  the  velum  and  close  the 
opening  from  the  pharynx  into  the  posterior  nares.  Thus  ali- 
mentary substances  and  fluids  are  prevented  from  escaping  into 
the  nose. 

It  matters  not,  therefore,  whether  the  imperfection  of  the 
velum  palati  be  the  result  of  accident  or  disease,  its  effects  upon 
deglutition  are  tlie  same.  In  proportion  as  the  lesion  or  defi- 
ciency is  great,  Avill  this  operation  be  rendered  difficult  and  em- 
barrassing. M.  Delabarre  mentions  the  case  of  an  individual, 
who,  in  consequence  of  an  imperfection  of  the  palate,  could 
swallow  no  fluids  without  a  part  being  returned  by  the  nose.  To 
obviate  this  inconvenience,  he  had  to  throw  his  head  sufficiently 
far  back  to  precipitate  them  into  the  oesophagus.  This  is  an  ex- 
pedient to  which  others,  thus  affected,  have  been  compelled  to 
resort. 


DEFECTS    OF    THE    PALATINE    ORGANS,  821 

Imperfection  of  speech  always  results  from  an  opening  in  the 
palate,  for  this  gives  to  the  voice  a  nasal  twang,  and  renders  the 
formation  of  some  sounds  impossible.  The  loss  of  the  teeth, 
though  never  to  the  same  extent,  is  productive  of  the  same  effect. 
To  comprehend  fully  the  manner  in  which  a  lesion  of  the  palate 
may  affect  the  utterance  of  speech,  it  will  be  necessary  to  under- 
stand the  agency  \vhich  the  several  parts  of  the  mouth  have  in 
the  formation  of  articulate  sounds.  Speech  consists  in  the 
sounds  produced  by  the  organs  of  the  glottis  modified  by  the 
organs  of  the  mouth.  The  modulation  of  the  voice,  that  is,  the 
raising  or  lowering  of  its  pitch,  is  accomplished  by  the  vocal 
cords  of  the  glottis :  but  the  articulation  of  the  consonants  re- 
quires the  co-operation  of  all  the  movable  and  fixed  parts  of  the 
mouth — pharynx,  palate,  tongue  and  lips,  teeth  and  palatine 
arch.  Hence,  if  any  of  these  be  defective  or  wanting,  the  power 
of  forming  some  of  these  sounds  is  wholly  lost,  of  others  very 
much  impaired ;  hence  also  the  ability  to  sing  is  much  less  inter- 
fered with  than  the  power  of  distinct  speech.  The  tongue  has 
a  remarkable  power  of  adapting  itself  to  the  loss  of  teeth  and 
of  some  other  parts,  so  as  measurably  to  correct  the  effect  on 
speech  ;  but  the  effect  of  the  loss  of  the  hard  or  soft  palate  upon 
the  voice  cannot  be  remedied  in  any  such  way. 


CHAPTER     THIRD 


MANNER  OF  REMEDYING  DEFECTS  OF  THE  PALATINE 

ORGANS. 


Defects  of  the  palatine  organs  are  sometimes  remedied  by 
means  of  a  surgical  operation,  termed  stafhylorafhy  ;  but  more 
frequently,  by  supplying  the  deficiency  of  the  natural  parts  with 
a  mechanical  substitute.  The  operation  of  staphyloraphy,  when 
it  can  be  successfully  performed,  is  the  best  and  most  perfect 
method  that  can  be  adopted  for  remedying  imperfection  of  the 
parts  in  question.  The  application  of  a  mechanical  substitute, 
however,  though  it  may  not  completely  restore  the  functions  de- 
pendent upon  the  integrity  of  the  natural  parts,  will  often  so 
improve  them,  as  to  render  the  inconveniences  resulting  from 
such  imperfection,  scarcely  perceptible. 

In  treating  upon  these  methods,  we  shall  first  describe  the 
operation  of  staphyloraphy,  and,  afterwards,  the  various  me- 
chanical appliances  employed  for  the  purpose,  which  are  desig- 
nated by  the  names  of  obturators  and  artificial  palates. 

STAPHYLORAPHY. 

It  rarely  happens,  except  in  cases  of  congenital  fissure,  that 
the  operation  of  staphyloraphy  can  be  successfully  performed, 
and  only  then,  when  the  edges  of  the  cleft  velum  are  firm  and 
can  be  easily  brought  together.  There  are  many  ways  in  which 
the  success  of  the  operation,  even  in  cases  apparently  the  most 
favorable,  may  be  defeated.  For  example,  the  ligatures  may  be 
detaciied  by  attempting  to  swallow,  or  clear  the  throat;  or  by 
coughing  or  sneezing ;  or  by  inflammation  and  sloughing  of  the 
parts.  Unless  these  are  carefully  guarded  against,  the  best 
efforts  of  the  surgeon  may  be  frustrated. 

Ihe  idea  of  this  operation  was  first  conceived  by  an  ingenious 
French  dentist,  by  the  name  of  Le  Monnier,  who  attempted, 
and  with  success,  to  perform  it  as  early  as  the  year  1764.     But 


STAPHYLORAPHY.  823 

for  more  than  half  a  century  afterward,  it  does  not  seem  to  have 
attracted  any  attention,  or  to  have  been  generally  known  to  the 
medical  profession.  In  1819,  however,  M.  Roux,  a  celebrated 
French  surgeon,  and  author  of  an  able  memoir  upon  the  subject 
published  in  1825,  performed  the  operation  upon  Dr.  Stephens, 
a  young  American  physician.*  In  1820,  it  was  performed  for 
the  first  time  in  the  United  States,  by  Dr.  J.  C.  Warren,  of 
Boston,  and  in  1822  in  England,  by  Mr.  ALCOCK.f  Now,  it  is 
classed  among  the  regular  operations  of  surgery. 

As  the  success  of  the  operation  depends  in  great  degree  upon 
the  consent  of  the  patient,  he  should,  as  a  general  rule,  have 
attained  a  sufficient  age  to  enable  him  to  appreciate  its  import- 
ance, before  it  is  performed.  The  late  Dr.  HuUihen,  of  Wheeling, 
Va.,  however,  stated  that  he  had  once  performed  the  operation 
with  success  on  a  child  nine  years  of  age,  but  the  author  thinks 
that  it  is  generally  better  to  defer  it  until  after  the  fifteenth  or 
sixteenth  year ;  and  the  natural  excitability  of  the  parts  should 
previously  be  as  much  lessened  as  possible,  by  frequently  touch- 
ing and  moving  them  about  with  the  finger.  This  should  be 
done  several  times  a  day,  for  at  least  two  weeks  before  the  opera- 
tion is  attempted,  and  during  this  time,  the  patient  should  be 
restricted  to  a  spare  diet. 

The  earlier  operations  of  staphyloraphy,  or  velo-synthesis, 
consist  in  removing  the  margins  of  the  divided  velum  with  a  pair 
of  curved  scissors,  as  recommended  by  M.  Roux,  or  a  double- 
edged  knife,  and  holding  the  raw  edges  in  contact  with  each 
other  until  a  union  takes  place. 

A  number  of  ingeniously  contrived  instruments  have  been 
invented  for  the  performance  of  the  operation ;  but  those  really 
necessary  are  a  sharp  hook,  a  double-edged  knife,  short  curved 
needles,  a  needle-holder  {porte-aiguille)^  strong  waxed  ligatures, 
and  a  pair  of  long-handled  curved  forceps,  and  scissors ;  other 
instruments  may,  in  some  cases,  be  recjuired.  In  addition  to  the 
above,  water,  towels,  and  one  or  more  assistants,  will  be  needed. 

*  We  are  informed  by  Velpeau,  in  his  Elements  of  Operative  Surgery,  p.  428,  that 
M.  Colombe  performed  the  operation  on  a  dead  subject  in  181.3,  and  in  1815  endea- 
vored to  prevail  on  a  patient  to  permit  him  to  repeat  it,  but  without  success.  In 
1817,  too,  M.  Graefa;  published  in  Hufeland's  Journal  some  details  concerning  it,  but 
the  subject  elicited  no  interest  until  M.  Roux  performed  the  operation  in  ISll*. 

t  Dr.  Reese's  Appendix  to  Cooper's  Surgical  Dictionary. 


824 


STAPHYLORAPHY. 


Tlius  prepared,  the  patient,  after  having  been  previously  sub- 
jected to  the  necessary  prepa- 
ratory treatment,  should  be 
placed  in  a  chair  facing  a  good 
light,  with  his  head  firmly  sup- 
ported by  an  assistant,  and  his 
mouth  open.  The  operation 
may  be  commenced  by  insert- 
ing the  hook  into  the  margin 
of  the  velum,  near  its  most 
dependent  part,  on  the  left  side 
of  the  fissure,  in  the  manner 
represented  in  Fig.  293.  This 
instrument,  held  by  an  assist- 
ant, should  be  depressed  so  as 
to  make  the  margin  slightly 
tense.  The  point  of  the  double- 
edged  knife  ma}-  now  be  placed  below  the  most  dependent  part 
of  the  velum,  a  little  to  the  left  of  where  the  hook  is  inserted 
(Fig.  293),  and  carried  from  below  upward  until  it  has  reached 
the  angle  of  the  fissure,  removing  a  strip  from  the  margin  about 
one  line  in  width.  This  operation  may  be  repeated  in  the  same 
way  on  the  opposite  side  of  the  fissure.  Or  the  first  part  of  the 
operation  may  be  continued,  in  the  manner  described  by  Dr. 
Mutter ;  changing  the  knife  from  the  right  to  the  left  hand,  and 
directing  the  assistant  holding  the  hook  to  pass  his  hand  across 
and  a  little  above  the  face  of  the  patient,  so  as  to  keep  up  a 
constant  traction  upon  the  strip  of  mucous  membrane  removed 
by  the  first  cut.  The  right  margin  of  the  fissure  being  then 
made  tense,  the  knife  is  carried  from  above  downward;  thus 
completing,  by  a  single  incision,  the  whole  of  this  part  of  the 
operation. 

Further  procedure  should  be  suspended  until  the  hemorrhage, 
seldom  very  great,  shall  have  partially  subsided.  A  needle, 
armed  with  a  well  waxed  hgature,  and  held  in  a  pair  of  suitable 
forceps  (porte-aiguille)  should  be  passed  from  before  backward 
through  the  most  dependent  part  of  the  left  margin,  about  three 
lilies  from  the  edge.  As  soon  as  it  is  seen  on  the  opposite  side. 
It  should  be  grasped  by  the  assistant  with  a  pair  of  longhandled 


STAPHYLORAPIfY. 


«2;3 


forceps,  and   drawn   through  ;  then  seized  again  by  the   porte- 

aiguille,  and   passed,  from  beliind  forward,   through   the   right 

margin  of  the  velum  directly  opposite  to  the  ligature  in  the  left. 

Fig.  294. 


Fig.  295. 


Fig.  29(; 


(Figs.  294,  295.)  After  the  patient  has  rested  a  few  minutes,  a 
second,  third,  and,  when  necessary,  a  fourth  ligature  should  be 
introduced.  The  passage  of  the  needle  thi-ough  the  left  margin 
of  the  velum,  from  before  backward,  is  represented  in  Fig.  294, 
and  in  Fig.  295,  through  the  right  margin,  fi-om  behind  forward. 
The  licrature  first  introduced  should  now  be  tied,  bringinii  tho 
edges  of  the  velum  close  to- 
gether, and,  afterward,  the 
second  and  third,  cutting  off 
the  ends  of  each.  After  the 
first  knot  of  the  ligature  is 
tied,  some  precaution  should 
be  used  to  prevent  this  from 
slipping,  while  the  second  is . 
tied.  The  method  adopted 
by  M.  Roux  for  knotting  the 
ligature  is,  to  make  the  first 
fold  of  the  knot  with  the 
fore-fingers  of  each  hand 
placed  back  to  back,  and  after 
this  has  been   drawn  suffici- 


53 


MiO 


STAPHYLORAPHY. 


cntly  tight,  it  is  seized  by  an  assistant  with  a  pair  of  forceps, 
and  held  until   the  second  and  last  turn  of  the  knot  is  made. 

In  Fig.  296.  three  ligatures  are 
shown  in  place,  preparatory  to 
being  tied,  which  last  process  is 
seen  completed  in  Fig.  297. 

Some  surgeons  use  two  needles 
for  each  ligature,  instead  of  one, 
as  in  the  method  just  described 
— one  at  each  end,  and  introduce 
them  from  behind  forward,  one 
through  each  margin  of  the 
divided  velum. 

The  following  cut,  Fig.  298, 
copied  from  Liston's  and  Miit- 
ter's  Surgery,  represents  the 
Deedle-holder,  or  "porte,"  of 
Schwerdt,  which  is,  perhaps,  as  well  adapted  to  the  purpose  as 
any  instrument   that   can   be  employed."    Dr.    Physic's  forceps 

Fig.  298. 


liave  also  been  used,  but  Dr.  Mutter  thinks  this  is  a  preferable 
instrument. 

The  late  Dr.  Ilullihen,  who  performed  the  operation  several 
times,  invented  a  very  ingenious  needle-holder,  which,  we  have  no 
doubt,  will  ultimately  supersede  the  use  of  most  others.  A  de- 
scription of  the  instrument,  together  with  his  method  of  per- 
forming the  operation,  is  given  in  the,  fifth  volume  of  the  Ameri- 
can Journal  of  Dental  Science. 

After  the  operation  has  been  performed,  the  patient  should  be 
directed  to  keep  his  mouth  closed,  maintain  perfect  quiet;  avoid 
coughing,  sneezing,  or  even  spitting,  and  the  use  of  all  solid 
food.  He  should  take  very  little  aliment,  and  this  only  at  long 
intervals.  For  appeasing  the  cravings  of  the  hunger  with  which 
some  suffer,  Dr.  Mutter  recommends  thin  calf's-foot  jelly,  or 


STAPHYLORAPHY.  827 

what  is  known  as  cold  custard  slip,  as  the  best  nourishment 
that  can  be  used  ;  but  he  thinks  that  nothing  should  be  given 
until  the  end  of  the  second  or  third  day  after  the  operation  has 
been  performed. 

In  the  performance  of  the  operation  of  staphyloraphy,  how- 
ever, different  surgeons  employ  different  instruments,  and  adopt 
different  methods  of  procedure.  Professor  N.  R.  Smith,  of 
Baltimore,  who  has  performed  the  operation  many  times,  and  in 
a  good  proportion  of  cases  with  perfect  success,  employs  a  very 
simple  lance-shaped  needle,  mounted  on  a  handle,  and  having 
near  its  point  a  slit  which  opens  toward  the  handle.  The  needle  is 
broader  in  front  of  this  slit  or  eye  than  behind  it,  which  renders 
the  passage  of  the  back  part  more  easy.  Armed  with  a  ligature, 
the  curved  portion  of  the  needle  is  carried  beyond  the  fissure, 
and  its  point  introduced  behind  the  middle  of  the  uvula;  as  soon 
as  it  has  come  through  far  enough  to  expose  the  ligature  in  the 
slit,  this  is  taken  hold  of  with  a  tenaculum,  disengaged  from  the 
slit,  and  the  needle  is  then  withdrawn.  A  second  ligature,  in 
like  manner,  is  introduced  half  an  inch  higher  up,  and,  if  neces- 
sary, a  third  at  an  equal  distance  from  the  second.  With  the 
ends  of  the  ligature  passed  through  the  uvula,  this  part  is  drawn 
forward,  until  the  fissure  in  the  soft  palate  shall  assume  nearly  a 
horizontal  position ;  its  edges  are  then  cut  off  with  a  pair  of 
scissors,  either  straight  or  curved  laterally,  or  else  with  a  bis- 
toury and  a  pair  of  forceps.  This  done,  the  ligatures  are  tied, 
and  the  ends  cut  off.* 

Dr.  J.  C.  Warren,  of  Boston,  who  has  performed  the  opera- 
tion JSb  number  of  times,  uses  a  needle  of  his  own  invention,  with 
a  movable  point.  His  son,  Dr.  J.  M.  Warren,  has  also  per- 
formed the  operation  frequently,  and  with  very  great  success. 
When  the  fissure  extends  up  into  the  hard  palate,  he  dissects  the 
mucous  membrane  from  the  bone  on  each  side,  carrying  his 
knife  sufiiciently  forward  toward  the  alveolar  border  to  form  a 
flap  broad  enough  to  meet  a  like  one  from  the  opposite,  along 
the  median  line.     This  is  the  flap  operation. 

When  the  fissure  is  so  wide  as  to  prevent  the  margins  of  the 
velum  from  being  brought  together,  Dr.  Mettauer,  of  Virginia, 
recommends  making  several  lateral  incisions  through  the  mucous 

«  Appendix  to  Cooper's  Surgical  Dictionary,  by  Dr.  Reese,  p.  126. 


828 


STAPIIYLORAPHY. 


membrane,  with  a  view  to  increase  the  extent  of  the  velum,  and 
thus  permit  their  edges  to  be  brought  together.     For  supplying 

deficiency  of  structure,  Dieffen- 
bach  also  proposes  that  a  longi- 
tudinal incision  be  made  at  a 
short  distance  from  the  margin 
of  the  fissure,  as  in  Fig.  299, 
from  Dr.  Pancoasts  Operative 
Surgery.  The  last-named  gen- 
tleman has  just  performed  the 
operation  in  two  cases,  with 
success.  Dr.  Miitter,  of  Phila- 
delphia, who  has  been  very  suc- 
cessful in  the  operation,  has 
also  had  recourse  to  these  late- 
ral longitudinal  incisions,  with 
the  most  happy  results.* 
Suture  of  the  palate  is  always  difficult,  and  was,  in  former 
days,  anything  but  a  successful  operation,  by  reason  of  the  al- 
most impossibility  of  preventing  the  flaps,  when  united,  from 
being  dragged  asunder  by  the  muscles.  To  Fergusson  is  due 
the  great  credit  of  introducing  a  new  principle  of  treatment  in 
the  operation,  viz :  the  application  to  it  of  myotowij^  and  thus 
paralyzing  the  movements  of  the  muscles  of  the  palate.  Fer- 
gusson found  that  the  chief  causes  of  failure  in  these  cases  was 
the  mobility  of  the  parts  and  the  traction  exercised  on  the  line 
of  union  by  the  muscles,  principally  the  levator  palati  and  the 
palato-pharyngeus.  In  order  to  obviate  this  tension,  he  con- 
ceived the  idea  of  dividing  the  muscles  causing  it. 

In  the  operation,  as  performed  by  Mr.  W.  Fergusson,  there 
are  four  distinct  stages.  In  the  first,  the  muscles  of  the  palate 
are  divided,  by  passing  a  curved  lancet-ended  knife  through  the 
fissure  behind  the  velum,  midway  between  its  attachment  to  the 
bones  and  the  posterior  margin,  and  about  half-way  between  the 
velum  and  the  end  of  the  Eustachian  tube.  By  cutting  deeply 
with  the  point  of  the  knife  in  this  situation,  the  levator  palati  is 
tlivided.  The  uvula  is  then  seized  and  drawn  forward,  so  as  to 
put  the  posterior  pillar  of  the  fauces  on  the  stretch,  which  is  to 


*  Vide  Liston's  and  Mutter's  Surgery,  p.  204. 


STAPHYLORAPHY.  829 

be  snipped  across  so  as  to  divide  the  palato-pharyngeus.  The 
next  step  in  the  operation  consists  in  paring  the  edges  of  tlie 
fissure  from  above  downward  by  means  of  a  sharp-pointed  bis- 
toury. This  is  best  done  by  seizing  the  lower  end  of  the  uvuhi, 
putting  it  on  the  stretch,  and  cutting  first  on  one  side  and  then 
on  the  other,  leaving  the  angle  of  union  to  be  afterward  re- 
moved. The  patient  should  then  be  alloAved  to  remain  quiet, 
and  to  gargle  the  mouth  with  cold  water  or  ice,  so  as  to  stop  the 
bleeding. 

When  this  is  arrested,  the  surgeon  proceeds  to  the  next  step 
— that  of  introducing  the  sutures — which  may  be  done  by  means 
of  a  ngevus-needle,  armed  with  a  moderate  sized  thread,  passed 
from  beloAv  upward  on  the  left  side  of  the  fissure,  about  a  quar- 
ter of  an  inch  from  the  margin.  The  thread  should  now  be 
seized  with  forceps,  and  one  end  of  it  pulled  forward  through 
the  fissure.  This  again  may  be  threaded  in  the  needle  and 
passed  through  the  opposite  side  of  the  fissure  from  behind  for- 
ward through  the  right  side.  As  the  point  of  the  needle  appears, 
the  thread  should  be  again  seized,  and  the  needle,  at  the  same 
time,  withdrawn;  and,  finally,  the  suture  is  tied  with  the  sur- 
geon's knot.  In  this  way,  from  two  to  four — in  any  case  a  suffi- 
cient number — of  sutures  may  be  passed,  according  to  the  extent 
of  the  fissure,  tied  tightly,  and  the  knot  cut  close. 

The  patient  must  next  be  put  to  bed,  and  every  care  taken  to 
avoid  any  movement  of  the  palate,  either  by  coughing,  spitting 
or  swallowing  the  saliva  ;  giving  soft  food  and  very  little  of  it. 
The  sutures  need  not  be  withdrawn  before  the  eighth  or  tenth 
day,  but  may  be  left  a  few  days  longer  if  union  be  not  surely 
obtained  at  the  period  mentioned.* 

The  operation,  already  described,  of  Dr.  Warren,  of  Boston, 
for  closing  fissure  of  the  hard  palate,  has  been  introduced  into 
England  by  Mr.  Pollock,  who,  with  the  assistance  of  his  pecu- 
liarly-constructed instruments,  proceeds  as  follows:  He  makes 
an  incision  along  the  edge  of  the  cleft,  at  the  junction  of  the 
nasal  and  palatal  mucous  membrane.  The  soft  covering  of  the 
hard  palate  is  carefully  dissected  or  scraped  from  the  bones  by 
means  of  curved  knives,  great  care  being  taken  that  the  mucous 

«  Vide  Medico-Chinirgical  Transactions,  vol.  28.  A\f-o  Erichsen's  Science  and  Art 
of  Surgery,  1869. 


830  STAPHYLORAPHY. 

membrane  and  its  subjacent  fibro-cellular  tissue  (which  varies 
greatly  in  thickness  in  different  cases)  are  not  perforated.  When 
this  has  been  well  loosened  on  either  side,  it  will  be  found  to 
hanff  down  like  a  curtain  from  the  vault  of  the  mouth — the  two 
parts  coming  into  apposition  along  the  median  line,  or  possibly 
overlapping.  The  edges  being  then  smoothly  pared,  are  to  be 
brought  together  by  means  of  a  few  points  of  suture  introduced 
in  the  ordinary  way,  and  without  any  dragging.  The  knots 
having  been  tied,  the  patient  must  be  confined  to  bed  for  several 
days,  and  nourished  with  an  abundant,  but  pulpy,  diet. 

In  dividing  the  levator  palati  muscle,  for  relaxing  the  edges 
of  a  fissured  soft  palate,  Mr.  Pollock  adopts  a  practice  different 
from  that  employed  by  Mr.  Fergusson,  as  already  described. 
Instead  of  cutting  from  behind,  he  passes  a  ligature  through 
the  curtain  of  the  soft  palate,  so  as  to  contract  and  draw  it  for- 
ward; and  then,  pushing  a  narrow-bladed  knife  through  the  soft 
palate  to  the  inner  side  of  the  hamular  process,  by  raising  the 
handle  and  depressing  its  point,  he  readily  divides  the  muscular 
fibres.  This  method  is  safer  than  that  of  Mr.  Fergusson  and 
easier  to  perform ;  and  the  gap  that  is  left  closes  w  ithout  diffi- 
culty by  granulation,  and  appears  to  assist  in  relieving  the  ten- 
sion of  the  parts.* 

Ligatures  of  silk  or  thread  Avere  formerly  used  in  this  opera- 
tion and  in  all  others  of  a  similar  nature;  but  they  have  the 
disadvantage  of  cutting  out  and  of  promoting  suppuration.  To 
our  distinguished  friend.  Dr.  Marion  Sirams,  belongs  the  merit 
of  having  introduced  in  surgery  tlie  employment  of  metallic  su- 
tures, principally  of  silver  wire,  to  the  exclusion  of  those  of 
organic  material.  The  intelligence  and  patience  of  Dr.  Simms 
deserve  our  admiration;  and  his  unwearied  efforts  in  perfecting 
the  operation  for  the  cure  of  vesico-vaginal  fistula — an  operation 
which  he  has  made  peculiarly  his  own — are  rewarded  by  the  re-i 
spect  and  gratitude  of  the  humane  and  enlightened  of  all  coun- 
tries. 

A\  hen  the  inflammation  which  follows  the  operation  is  very 
severe,  it  should  be  combated  by  general  and  local  bleeding,  and 
such  other  antiphlogistic  means  as  the  nature  of  the  case  may 
seem   to  demand.     When  the  inflammation  is  accompanied  by 

•=■■  Vide  Erichsen's  Science  and  Art  of  Surgery. 


STAPHYLORAPHY, 


331 


cough,  Dr.  Mutter  recommends  the  administration  of  opiates. 
The  same  author  recommends,  in  case  sloughing  of  the  parts 
takes  place,  the  application,  with  a  camel's-hair  pencil,  of  a  so- 
lution of  the  nitrate  of  silver,  or  a  mixture  of  creosote  and  water, 
three  or  four  times  a  day. 

It  often  happens,  that  an  opening  remains  in  the  palate  after 
the  velum  has  been  successfully  united.  This  may  sometimes  be 
closed  by  the  granulation  of  the  edges  of  the  cleft,  which  may 
be  induced  by  the  application  of  caustic  or  the  actual  cautery. 
Dieffenbach  has  employed,  with  success,  a  concentrated  tincture 
of  cantharides,  applied  several  times  a  day  to  the  edges  of  the 
opening.*  By  some,  the  actual  cautery  is  preferred;  but  if  the 
latter  be  used,  it  should  only  be  heated  sufficiently  to  blister  the 
parts. t  The  nitrate  of  silver  and  caustic  potash  have  been 
used,  but  there  is  danger  of  causing  a  greater  loss  of  substance 
by  the  use  of  these  powerful  caustics  than  can  be  gained  by  the 
granulations  which  they  induce. 

A  surgical  operation  is  seldom   performeil  for  the  purpose  of 

closing  a  simple  opening  in  the 

=•  '■  ^  '^  Fig.  300. 

hard  palate.  It  has  been  recom- 
mended, how'ever,  by  some  sur- 
geons, and  when  the  hole  is  not 
very  large,  the  operation  of 
Btapltyloplasty  may  be  success- 
fully performed.  In  Fig.  -300, 
from  Dr.  Pancoast's  Operative 
Surgery,  the  operation,  as  per- 
formed by  the  author  of  this 
valuable  work,  is  represented. 
So  perfectly  is  it  exhibited  in 
the  cut,  that  we  do  not  deem 
any  further  description  neces- 
sary. In  the  majority  of  cases 
of  this  kind,  however,  an  artificial  obturator  or  palate  will  be 
found  necessary. 

*  British  and  Foreign  Medical  Review,  for  April,  1840. 

•j"  Dr.  Ilullihen  on  Cleft  Puliite.  in  Am.  Jour.  Dent  Science,  vol.  a,  |).  17.''. 


8:^2  ARTIFICIAL   OBTURATORS    AND    PALATES. 


ARTIFICIAL  OBTIRATORS  AND  PALATES. 

Although,  by  the  operation  of  staphyloraphy,  the  use  of  me- 
chanical contrivances  for  remedying  imperfections  of  the  palate 
are  often  rendered  unnecessary,  yet,  in  the  majority  of  cases,  it 
is  only  hy  such  means  that  any  relief  can  be  afforded.  Artifi- 
cial palates  and  obturators  have  been  employed  for  a  long  time. 
Both  of  these  terms  signify  one  and  the  same  thing,  namely: 
an  instrument  to  close  or  stop  an  opening  in  the  palate.  The 
former,  however,  is  generally  applied  to  a  simple  plate  fitted  to 
the  palatine  arch;  the  latter  to  a  plate  surmounted  by  a  piece 
of  sponge,  wings,  or  a  drum  or  air-chamber,  passing  up  into  or 
through  the  opening,  and  designed  either  to  hold  up  the  plate 
•  •r  to  fill  the  aperture.  When  a  velum  is  attached,  the  instru- 
ment is  termed  an  artificial  palate  with  a  velum. 

They  were,  according  to  Guillemean,  applied  by  the  Greek 
physicians  ;  but  it  is  to  that  celebrated  French  surgeon,  Ambrose 
Pare,  that  we  are  indebted  for  the  first  description  of  an  appli- 
ance of  this  sort.  This  author  has  furnished  an  engraving  of  an 
obturator  which  ho  had  constructed  in  1585,  consisting  of  a  me- 
tallic plate,  probably  of  silver  or  gold,  fitted  into  an  opening  in 
the  vault  of  the  palate.  It  was  held  up  by  means  of  a  piece  of 
sponge,  fastened  to  a  screw  in  an  upright  attached  to  the  upper 
surface  of  the  plate.  The  employment  of  sponge,  however,  was 
found  to  be  objectionable,  as  the  secretions  of  the  nasal  cavities, 
which  it  absorbed,  soon  became  insufferably  offensive;  notwith- 
standing which,  it  continued  to  be  used  for  a  long  time.  Ulti- 
mately, however,  it  was  superseded  by  an  obturator  invented  by 
Fauchard.  This  was  held  up  by  means  of  wings,  which  turned 
on  a  pivot.  Both  of  these  obturators,  however,  exerted  a  hurt- 
ful influence  upon  the  surrounding  parts,  as  the  pressure  pro- 
duced by  the  sponge  and  wings  caused  them  to  be  gradually 
destroyed,  and  thus  augmented  the  evil  they  were  designed  to 
remedy;  consequently,  their  use  has  been  wholly  abandoned. 
^\  e  do  not,  therefore,  deem  it  necessary  to  give  a  description  of 
«'uher.  We  will,  however,  quote  a  passage  from  Bourdet  upon 
the  subject.  In  alluding  to  the  impropriety  of  having  recourse 
to  any  appli.uice  which  has  a  tendency  to  counteract  the  curative 


ARTIFICIAL    OBTURATORS     AND    PALATES.  833 

efforts  of  nature,  he  says:  "Before  considering  tlie  cicatrized 
perforations  of  the  palate  as  being  of  a  nature  incapable  of  di- 
minishing in  diameter,  practitioners  should  satisfy  themselves, 
thoroughly  and  beyond  doubt,  that  such  is  the  case.  We  do  not 
think  that  this  condition  of  permanency  can  exist,  for  positive 
facts  attest  the  contrary;  and  as  holes  made  in  the  cranium  with 
the  trepan  close  almost  entirely,  in  like  manner  those  of  the 
palate  constantly  diminish."  Numerous  examples  might  be  ad- 
duced if  it  were  necessary  to  prove  the  impropriety  of  sustain- 
ing an  obturator  by  any  fixtures  which  act  upon  the  lateral 
parts,  as  they  necessarily  tend  to  increase  the  dimensions  of  the 
opening  in  the  palate.  Cases  do,  however,  sometimes  occur,  in 
which  no  other  means  of  support  seem  to  be  afforded,  and  then 
the  dentist  may,  perhaps,  be  justifiable  in  using  them.  We 
question,  however,  even  in  such  cases  where  atmospheric  pressure 
cannot  be  obtained,  and  there  are  no  teeth  for  clasping,  if  the 
use  of  spiral  springs,  attached  to  a  partial  lower  piece  or  to  caps 
placed  over  the  lower  molars,  would  not  be  preferable  to  this 
very  objectionable  prominence  on  the  upper  surface  of  obtu- 
rators. 

With  a  view  of  obviating  the  objections  which  have  been 
mentioned  as  existing  to  the  obturators  of  Pard  and  Fauchard, 
Bourdet  proposes  to  employ  simply  a  metallic  plate,  fitted  to  the 
vault  of  the  palate  and  large  enough  to  cover  the  opening,  with 
two  lateral  prolongations,  one  on  each  side,  extending  to  the 
teeth,  to  which  they  are  fastened  by  means  of  ligatures.  This 
was  also  found  to  be  objectionable,  as  the  ligatures  were  produc- 
tive of  constant  irritation  to  the  gums ;  moreover,  they  did  not 
hold  the  plate  in  place  with  sufficient  stability,  and  its  use  was 
soon  abandoned.  But  these  objections  were  both  obviated,  as 
we  have  stated  in  another  place,  by  an  improvement  made  by  M. 
Delabarre,  which  consists  in  the  employment  of  clasps,  instead 
of  ligatures  attached  to  lateral  branches  of  the  plate  ;  to  prevent 
these  from  slipping  too  high  up  upon  the  teeth,  he  attached  to 
each  a  kind  of  spur,  which  was  so  bent  as  to  come  down  over  the 
grinding  surface  of  the  tooth  to  which  it  was  applied.  The  last 
named  author,  also,  made  another  modification,  which  consisted 
in  the  application  of  a  drum  to  the  upper  surface  of  the  plate 
(Fig.  301).     The  object  of  this  was  to  prevent  the  accumulation 


834 


ARTIFICIAL    OBTURATORS    AND    PALATES. 


Fig.  301. 


of  mucous  fluids  from  the  nose,  in  the  cul-de-sac,  formed  by  sim- 
ply closing  the  opening  below ;  also  to  prevent  fluids,  in  swal- 
lowint^,  from  passing  up  between  the  obturator  and  soft  parts, 
through  the  opening  into  the  nose. 

The  manner  of  constructing  an  obturator,  with  a  drum  upon 
its  upper  surface,  is  as  follows :    First  take  an  impression  of  the 

entire  palatine  vault  and  al- 
veolar ridge  in  wax.  From 
this,  a  plaster  model  and  metal- 
lic dies  are  procured,  in  the 
manner  described  in  a  former 
chapter ;  a  gold  plate  is  then 
swaged  between  the  two  last, 
a  little  larger  than  the  open- 
ing in  the  palate,  with  a  broad 
arm  on  each  side,  extending 
to  the  bicuspid  or  molar  tooth,  to  which  a  broad  clasp  is  fitted 
and  soldered.  Secondly,  an  impression  of  the  opening  in  the 
vault  of  the  palate  is  taken  with  wax,  properly  softened  and 
placed  upon  the  upper  surface  of  the  palate  plate,  using  the 
precaution  to  prevent  forcing  it  up  too  far  through  the  aper- 
ture ;  this  is  next  trimmed  where  it  comes  in  contact  with  the 
plate,  so  that  it  shall  not  be  quite  as  Large  as  the  opening ;  it  is 
then  covered  with  plaster,  after  which  a  metallic  die  and  counter- 
die  is  taken,  then  a  gold  plate  is  swaged  between  the  two,  and 
this  last  is  fitted  and  soldered  to  the  palatine  plate.  The  piece, 
after  being  properly  finished,  is  ready  to  be  applied. 

An  obturator  of  this  description  is  seldom  required,  except 
in  those  cases  where  the  opening  in  the  palate  is  connected  with 
the  velum,  so  that  by  the  contraction  of  its  muscles,  the  parts 
are  raised  from  the  plate  in  such  a  manner  as  to  permit  fluids, 
in  the  act  of  deglutition,  to  pass  up  into  the  nose.  In  this  case 
it  will  not  only  prevent  this  'difficulty,  but  will  also  prevent  the 
fluids  of  the  nose  from  accumulating  in  the  opening  above  tiie 
plate. 

It  is  of  the  greatest  importance  that  an  artificial  palate  or 
obturator  should  be  executed  in  the  most  perfect  manner,  and  be 
made  to  fit  accurately  to  all  the  parts  with  which  it  is  to  be  in 
contact,  so  that  it  may  not  produce  the  slightest  irritation  or 


i 


ARTIFICIAL    OBTURATORS     AND    PALATES. 


835 


exert  undue  pressure  upon  any  of  the  surrounding  parts.  As  in 
the  case  of  the  application  of  a  dental  substitute,  the  piece  should 
not  be  applied  while  any  of  the  teeth,  especially  those  of  the 
upper  jaw,  are  in  an  unhealthy  condition.  The  gums  and  sockets 
of  the  teeth  should  also  be  free  from  disease.  The  drum  evi- 
dently offers  the  same  impediment  to  nature's  efforts  in  closing 
the  opening  as  the  obturators  before  mentioned ;  on  this  score, 
therefore,  it  is  equally  objectionable.  The  best  way  doubtless 
to  prevent  the  accumulation  of  secretions,  food,  &c.,  is  to  remove 
the  piece  two  or  three  times  every  day,  and  thoroughly  cleanse 
both  it  and  also  the  teeth  to  which  the  clasps  are  applied. 

When  the  opening  in  the  palate  is  small  and  has  no  connection 
with  the  velum,  it  is  unnecessary  to  raise  the  upper  surface  of 
the  plate  by  attaching  a  drum  or  air-chamber  to  it.  If  it  be 
accurately  fitted  to  the  vault  of  the  palate,  it  will  effectually  pre- 
vent fluids  in  deglutition  from 
passing  up  into  the  nasal  cavities, 
or  the  escape  of  any  portion  of 
the  voice  through  the  opening ; 
and  by  frequently  removing  the 
plate,  it  will  prevent  the  accu- 
mulation of  the  secretions  in  the 
cul-de-sac.  A  simple  plate  like 
the  one  represented  in  Fig.  302, 
will  be  all  that  is  required  to 
remedy  the  defect ;   and  this,  in 

fact,  will  probably  be  found  the  best  form  for  all  cases,  whether 
the  openings  be  large  or  small. 

Although  the  stability  of  the  plate  will  very  much  depend 
upon  the  width  of  the  clasps,  the  latter  should  never  be  so  wide 
as  to  press  upon  the  gums  around  the  necks  of  the  teeth  to  which 
they  are  applied,  as  in  that  case  they  will  be  productive  of  irrita- 
tion, and  ultimately  cause  the  destruction  of  the  alveoli  and  loss 
of  the  teeth.  Nor  should  they  press  upon  the  teeth  so  as  to  force 
them  apart  or  draw  them  toward  each  other,  as,  in  either  case, 
the  effect  would  be  gradually  to  loosen  and  displace  the  organs. 
In  short,  the  same  precautions  are  necessary  in  the  application 
of  clasps  to  an  artificial-palate  plate,  as  to  one  designed  merely 
to  serve  as  a  support  for  artificial  teeth. 


836  ARTIFICIAL    PALATE,    VELUM    AND    UVULA. 

All  the  details  of  construction  are  the  same  in  the  case  or 
simple  obturators  as  in  the  making  of  an  upper  plate.  If  a  drum 
is  soldered  on  tlie  upper  side  of  the  plate  after  the  plan  of  De- 
sirahode,  or  if  a  very  deep  arch  is  made  shallower  by  soldering 
a  second  plate  on  the  lingual  side,  a  small  hole  must  be  made  for 
the  escape  of  heated  air  in  soldering,  Avhich  may  afterward  be 
closed  with  a  gold  screw,  and  filed  off  smoothly. 

AN  ARTIFICIAL  TALATE,  WITH  A  VELUM  AND  UVULA. 

It  sometimes  happens,  in  eases  of  congenital  fissure  of  the 
palate,  that  the  margins  of  the  velum  are  so  far  apart  as  to 
preclude  the  possibility  of  uniting  them  by  any  surgical  opera- 
tion, an<l,  at  other  times,  these  parts  are  wholly  destroyed  by 
ulceration ;  it  is  in  such  cases  that  an  artificial  velum  is  required, 
and  to  supply  which,  the  ingenuity  of  art  has  been  taxed  to  its 
fullest  extent.  Various  mechanical  contrivances  have  been  in- 
vented for  this  purpose ;  but  it  is  scarcely  necessary  to  sa}^  that 
until  quite  recently,  none  have  been  constructed  which  have 
performed,  to  any  considerable  extent,  the  functions  of  the 
natural  parts.*  Nor  has  this  desirable  object,  even  yet,  been 
very  fully  accomplished.  One  of  the  most  ingenious  contri- 
vances of  the  kind  which  has  ever  been  invented,  was  recently 
constructed  by  Mr.  Stearns,  surgeon,  of  London.  The  principle, 
however,  upon  which  it  acts,  was  not  altogether  original,  as  M. 
Delabarre   had    previously    constructed  a   piece   of   mechanism 

■•  The  inventions  and  iniiirovenients  above  referred  to  as  of  recent  development, 
date  back  as  far  as  1842.  Since  then,  great  advances  have  been  made  in  this  beauti- 
ful and  most  practical  art— greater,  perhaps,  than  all  made  prior  to  that  time.  Dr. 
Norman  (J.  Kingsley,  of  New  York,  has  for  several  years  past  made  a  specialty  of 
this  department  of  our  profession,  bringing  to  it  skill,  invention,  and  perseverance, 
which  have  produced  results  of  almost  marvelous  character.  To  the  knowledge  of 
the  writer,  patients  of  his,  whose  speech  up  to  a  few  months  ago  had  been  scarcely 
intelligible — some  of  them  so  for  more  than  forty  years— to-day  speak  with  a  dis- 
tinctness, precision,  volume,  and  finish  of  enunciation,  scarcely  distinguishing  them 
from  those  by  whom  they  are  surrounded;  a  slight  peculiarity  of  tone  is  alone  notice- 
able in  their  voice.  A  few  more  lessons  from  their  instructor,  Mr.  J.  H.  Brown,  the 
distinguished  elocutionist  of  that  city,  will,  it  is  believed,  entirely  remedy  this  only 
remaining  defect. 

We  have  given,  on  pages  84:5—853,  a  description  of  Dr.  Kingsley's  method  of  prac- 
tice, so  full  and  complete,  that  by  their  direction  any  operator  of  skill  and  capacity 
will  be  enabled  to  produce  results  of  the  same  practical  character  with  those  re- 
ferred to.  w   «    n 


ARTIFICIAL    PALATE.    VELUM    AND    UVULA.  837 

somewhat  similar  to  it,  and  composed  of  the  same  material, 
though  of  a  less  perfect  quality. 

The  contrivance  employed  by  Delabarre,  consisted  of  a  metal- 
lic plate,  bent  in  the  form  of  a  horse  shoe,  and  occupied  the 
place  of  the  posterior  part  of  the  naso-palatine  floor:  the  nasal 
portion  was  grooved  for  the  reception  of  the  vomer.  The  pala- 
tine surface  was  concave,  and  made  to  resemble  the  vault  of  the 
palate.  From  each  side  of  this,  an  arm  projected  to  the  first 
molar,  to  which  it  was  secured  by  means  of  a  clasp.  To  the 
posterior  portion,  a  piece  of  caoutchouc,  resembling  in  shape  the 
form  of  the  velum  and  uvula,  was  attached.  Although  this  in- 
strument is  represented  as  having  performed  all  the  functions  of 
the  velum,  so  far  as  deglutition  and  speech  are  concerned,  we 
are  disposed  to  doubt  the  entire  correctness  of  the  statement,  as 
it  has  failed  to  do  so  in  other  cases  in  which  it  has  been  applied, 
much  advantage,  hoAvever,  in  some  instances,  has  certainly  been 
derived  from  it. 

The  instrument  constructed  by  iNIr.  Stearns  consists  of  a  plate 
of  gold,  fitted  to  the  vault  of  the  palate,  in  the  usual  manner, 
and  to  the  upper  and  posterior  margin  of  wdiich  is  attaclied  a  fiat 
spiral  spring,  admitting  of  easy  vibration  backward  and  forward  : 
to  the  posterior  extremity  of  this  is  attached  a  flexible  velum, 
"  constructed  of  Mr.  Goodyear's  preparation  of  caoutchouc, 
which  has  the  property  of  resisting  the  action  of  both  oils  and 
acids,  and  at  the  same  time  of  sustaining  a  high  degree  of  heat. 
The  body  of  the  velum  consists  of  the  lamina  of  caoutchouc,  of 
a  somewhat  triangular  form,  and  of  the  same  size  and  shape  as 
the  vacant  space  it  is  intended  to  occupy — the  place  being  that 
which  would  be  indicated  by  imaginary  lines,  connecting  the 
opposite  sides  of  the  columns,  and  subtending  the  vertical  angle 
of  the  fissure,  at  which  point  the  velum  is  connected  to  tlie  pos- 
terior extremity  of  the  spiral  spring.  The  lamina,  constituting 
the  body  of  the  velum,  is  divided  into  three  pieces,  which  overlaj* 
each  other.  The  wings  project  obliquely  forward  and  outward 
from  each  lateral  margin  of  the  body,  and  being  made  to  con- 
form to  the  shape  of  the  columns  or  sides  of  the  fissure,  are  seen 
to  rest  upon  their  inner  and  anterior  surfaces,  thus  covering  a 
portion  of  the  soft  parts  which  constitute  the  boundaries  of  the 
posterior  fauces.     In  like  manner,  along  each  lateral  margin  of 


838  ARTIFICIAL    PALATE,    VELUM    AND    UVULA. 

the  bofly,  there  is  a  flange,  projecting  obliquely,  backward  and 
outward,  and  extending  along  down  the  posterior  surface  of  the 
column,  terminating  at  the  inferior  angle  of  the  velum.  In  this 
way  the  wing  and  flange  together,  on  the  same  side,  form  a 
groove  fitted  to  receive  the  fleshy  sides  of  the  fissure.  As  the 
preparation  of  caoutchouc  made  use  of,  presents  a  smooth  sur- 
face, and  yields  readily  to  the  slightest  pressure,  it  is  found  to 
permit  the  contact  and  muscular  action  of  the  surrounding  soft 
parts,  without  causing  any  irritation.  When,  therefore,  the 
sides  of  the  fissure  tend  to  approximate,  as  in  deglutition,  in 
gargling  the  throat,  or  in  the  utterance  of  some  of  the  short 
vowel  sounds,  the  three  parts  of  the  body  of  the  velum  slide 
readily  by  each  other,  thus  diminishing  the  extent  of  exposed 
surface,  and  thereby  imitating,  to  some  extent,  muscular  con- 
tractile action,  the  force  being  derived  from  without,  and  not,  of 
course,  contained  within  the  instrument.  During  the  efibrt  made 
in  speaking,  the  surrounding  muscular  parts  embrace  and  close 
upon  the  artificial  velum,  and  press  it  back  against  the  concave 
surface  of  the  pharynx.  The  passage  to  the  nares  being,  there- 
fore, temporarily  closed,  the  occlusion  of  sound  is  accomplished, 
and  articulation  made  attainable;  since  the  voice  or  sound,  as  it 
issues  from  the  glottis,  is  thereby  directed  into  the  cavity  of  the 
fauces,  and  confined  there  long  enough  to  receive  the  impressions 
made  upon  it  by  the  tongue,  lips,  etc.,  in  the  formation  of  the 
consonant  letters." 

A  velum  constructed  after  the  foregoing  manner,  Mr.  Stearns 
thinks,  will  be  found  applicable  in  all  cases,  though  it  will  be 
necessary,  in  the  construction  of  the  palate  plate,  to  give  it  such 
form  and  dimensions  as  may  be  required  by  the  peculiarities  of 
each  case.  For  example,  when  the  fissure  extends  through  the 
alveolar  border,  or  when  some  of  the  front  teeth  are  wanting,  it 
will  be  necessary  to  extend  it  sufficiently  forward  to  close  the 
opening,  or  serve  as  a  base  for  such  dental  substitutes  as  may  be 
required. 

Through  the  courtesy  of  Dr.  E.  G.  Tucker,  of  Boston,  we  are 
enabled  to  add  to  the  foregoing  description  an  engraving  of  the 
instrument,  made  from  a  duplicate,  which  he  sent  to  us  since  the 
publication  of  the  fourth  edition  of  this  work,  of  one  Avhich  was 
constructed  by  himself  and  his  brother.  Dr.  J.  Tucker. 


ARTIFICIAL    PALATE,    VELUM    AND    UVULA. 


839 


In  Fig.  303  is  seen  the  lower  surface  of  the  palate-plate  and 
anterior  surface  of  the  velum,     a,  the  palatine  plate;  b.  the  flat 


Fig.  303. 


FrG    304. 


spiral  springs,  extending  from  the  posterior  margin  of  the  plate 
to  the  upper  part  of  the  velum ;  c  c,  wings  of  the  velum ;  d  d, 
the  flange;   e,  the  central  portion. 

Fig.  304  shows  the  upper  surface  of  the  palate-plate,  and  the 
posterior  surface  of  the  velum  and  spiral  springs,  a,  palate- 
plate;  b,  spiral  springs;  c  e,  wings  of  the  velum  closed;  d  d,  the 
flange,  as  seen  above  the  wings ;  and  e,  the  central  portion  below 
the  wings,  and  intended  to  represent  the  uvula. 

Fig.  305  represents  the  velum  with  its  wings  separate  from  the 
plate,  showing  the  central  portion,  before 
being  attached  to  the  hook,  at  the  lower 
extremity  of  the  flattened  spiral  springs. 
In  Fig.  306  is  represented  a  side  view  of  the 
velum,  showing  the  groove  between  the 
flange  and  the  wings,  for  the  reception  of 
the  fleshy  sides  of  the  fissure. 

With  a  view  of  restoring  the  air  passages 
to  their  normal  condition  in  those  cases 
where  the  velum  has  been  lost  by  disease. 
Dr.  S.  P.  Hullihen  invented  an  instrument 
consisting  of  a  palate  plate  with  a  bi-globular 
valve  attached  to  it  in  such  a  manner  as  to  permit   the  egress 


Fig    30<;. 


840 


ARTIFICIAL    PALATE.    VELUM    AND    UVULA. 


Fig.  301 


and  ingress  of  the  desired  volume  of  air.  AVe  will  quote  from 
vol.  i.,  New  Series  of  the  American  Journal  of  Dental  Science, 
the  description  which  Dr.  II.  has  given  of  the  instrument. 

"An  artificial  palate  made  upon  this  plan  will  be  composed  of 
four  parts:  1st,  a  valve,  made  from  gold-plate,  as  thin  as  it  can 
well  he  worked  ;  2d,  a  spiral  spring  about  an  inch  long,  and  of 
the  size  usually  made  for  whole  sets  of  teeth;  3d,  a  slide,  one 
inch  and  a  half  in  length,  and  of  the  width  and  thickness  of  a 
common  watch-spring;  4th,  a  plate,  larger  or  smaller,  as  the 
case  may  require,  struck  up  in  the  usual  way,  to  fit  the  roof  of 
the  mouth. 

The  size  and  form  of  the  valve  is  ol)tained  by  taking  an  im- 
pression of  the  posteiior  opening  of  the  nares.  The  plate  com- 
posing it  should  be  struck  up  in  two  parts,  front  and  back,  which, 

when  soldered  together,makes 
a  hollow  body  (a),  as  shown 
in  Fig.  307.  xVt  the  upper 
end  of  the  valve  a  small  pin 
is  soldered,  the  point  of  which 
looks  downAvard,  and  of  suffi- 
cient thickness  to  fit  very 
tightly  in  one  end  of  the  spi- 
ral spring.  The  spiral  spring 
must  be  made  of  such  a  length 
a>  will  permit  the  valve  to  rest  slightly  upon  the  upper  surface 
of  the  remnants  of  the  lost  velum.  The  slide  has  a  pin  in  the 
jxtsterior  end,  looking  upward  to  receive  the  other  end  of  the 
spiral  spring  before  described.  The  anterior  end  of  the  slide 
has  a  small  button  looking  downward.  The  slide  is  attached  to 
the  plate  by  two  small  clasi>.s  {b  b),  as  represented  in  Fig.  308. 
ihe  pbite  may  be  made  to  cover  the  entire  roof  of  the  mouth, 
when  necessary;  or  it  may  be  made  only  sufficiently  large  to 
permit  the  mounting  of  the  slide.  These  different  plates,  when 
put  together,  jjurticidarly  if  the  plate  is  to  cover  the  whole  roof 
of  the  mouth,  make  a  plate  of  the  form  represented  by  Fig. 
307. 

Fig.  308  shows  the  attachment  of  the  spiral  spring  to  the 
valve  and  slide  [c  c).  The  staples  (b  b)  confine  the  slide  to  the 
l>l:ite.  and  there  is  a  ])utt(.n  {d)  on  the  end  of  the  slide,  by  which 


ARTIFICIAL    PALATE.    VELUM    AND    UVULA.  841 

the  valve  may  be  set  back  or  forward,  as  desired  by  the  patient, 
without  removing  the  phite  from  the  mouth. 

The  plate  shouhl  be  made  to  fit  the  several  parts  for  which  it 
is  intended,  with  great  ex- 
actness. The  plate  must 
fit  the  roof  of  the  mouth, 
and  the  teeth  to  which  it 
may  be  secured,  in  a  fault- 
less manner.  The  slide 
must  be  arranged  so  as  to 
permit  the  valve  to  be 
drawn  so  closely  against 
the  posterior  opening  of  the  nares,  as  to  close  them,  or  to  be 
pushed  back,  so  as  to  leave  them  entirely  unobstructed.  The 
spiral  spring,  as  I  have  before  remarked,  must  be  made  of  such 
a  length  as  will  allow  the  valve  to  rest  slightly  upon  the  upper 
surface  of  the  remnants  of  the  lost  velum.  The  valve  should 
be  sufficiently  W'ide  at  its  base  to  overlap  the  remnants  of  the 
velum  so  far  as  the  parts  on  each  side  will  permit,  without  pro- 
ducing irritation.  No  other  part  of  the  valve  than  the  base 
should  be  allowed  to  touch,  unless  when  brought  forward  against 
the  nares.  Unless  all  the  parts  are  so  arranged,  the  palate  will 
not  be  properly  constructed,  and  will  not,  of  course,  answer  the 
desired  end. 

"Thus  it  will  be  perceived  that  the  peculiarities  of  this  plate 
are:  First,  a  valve  to  fit  the  posterior  opening  of  the  nares; 
second,  the  attachment  of  this  valve  to  a  slide,  by  which  the 
patient  is  enabled  to  adjust  the  valve  while  in  the  mouth  in  such 
a  way  as  to  admit  through  the  nares  just  the  quantity  of  air  de- 
sired; third,  the  mounting  of  the  valve  on  a  spiral  spring,  which 
will  permit  it  to  vibrate  backward  and  forward,  as  the  breath  is 
inhaled  or  exhaled,  and  also  to  be  moved  by  any  muscular  action 
that  may  remain  in  the  remnants  of  the  lost  velum,  thereby  an- 
swering, to  a  great  extent,  the  purposes  of  a  velum." 

All  the  benefit  which  it  is  possible  to  be  derived  from  an  ap- 
pliance of  this  sort  may,  in  the  majority  of  cases,  we  believe,  be 
secured  by  this  instrument.  We  met  with  one  case,  however,  in 
which  the  muscular  action  of  the  remnant  of  the  velum  against 
the  valve  excited  so  much  irritation  and  nausea,  that  it  could 
54 


S4J 


AKTIFICIAL    PALATE,    VELUM    AND    UVULA. 


Tiot  be  worn.  To  obviate  which,  Dr.  A.  A.  Bhuirly  constructe*! 
;i  palate-pbite  of  a  J^oniewhat  difierent  shape,  as  may  be  seen 
from  Fi"s.  309,  310,  with  a  valve  composed  of  two  pieces. 


Fk;.  SO'J. 


Fig.  310. 


'i'o  the  posterior  edge  of  the  pahtte-pbite  another  plate  is  sol- 
dered. This  is  about  five-eighths  of  an  inch  in  width  where  it 
is  united  to  the  palate-plate,  and  half  an  inch  at  the  posterior 
extremity,  extending  upward  and  backward  nearly  three-fourths 
of  an  inch.  Tlie  two  pieces  composing  the  valve  are  fixed  to 
the  lower  surface  of  the  plate  in  such  a  manner  that  the  con- 
traction of  the  remnant  of  the  velum  moves  them  toward  each 
'•ther.  But  upon  its  relaxation  they  are  immediately  separated 
by  two  spiral  springs,  attached  to  the  upper  surface  of  the  palate- 
I  ••te  at  one  end,  and  to  two  delicate  springs  passing  through  the 
plate,  united  to  the  posterior  edge  of  the  first-mentioned  plate, 
and  attached  on  the  lower  surface,  one  to  each  part  of  the 
valve.  The  two  pieces  composing  the  valve  are  hollow,  each 
about  seven-eighths  of  an  inch  in  length,  and  of  a  conical  shape. 
The  bases  of  the  cones  are  placed  posteriorly  and  the  apices 
anteriorly.  The  surfaces  moving  on  the  plate  which  projects 
trom  the  jjalate-plate  are  flat,  and  the  outer  angle  of  the  base  of 
each  is  rounded.  But  the  several  parts  of  the  whole  appliance 
are  so  distinctly  shown  in  Figs.  309,  310,  that  we  do  not  deem 
a  further  description  of  them  necessary.  In  Fig.  309  is  seen  a 
lower,  and  in  Fig.  310  an  upper,  view  of  the  apparatus,  the 
two  pieces  composing  the  valve  being  purposely  separated  to 
show  them  mere  distinctly.      This  apparatus  had  been  worn  with 


DR.    KINGSLEY  S    ARTIFICIAL  VKLUM    AND    PALATE.  843 

the  greatest  comfort  and  satisfaction  for  six  months  prior  to  the 
issue  of  the  seventh  edition  of  this  work.  Its  subsequent  his- 
tory is  not  known.  The  patient's  speech,  although  not  per- 
fectly restored,  was  greatly  improved,  as  were  also  the  func- 
tions of  mastication  and  deglutition. 


DR.  KINGSLEY'S  ARTIFICIAL  VELUM  AND  PALATE. 

In  the  treatment  of  congenital  fissure  of  the  palate  by  me- 
chanical means,  with  a  view  of  improving  the  articulation,  this 
one  fundamental  principle  must  be  kept  in  view.  It  is  not  alone 
the  too  free  escape  of  sound  through  the  nares  that  causes  the 
defect  of  speech ;  but  it  is  the  absence  of  a  flexible  curtain  or 
valve,  Avhich  at  times  will  perfectly  close  the  passage  to  the  nares 
and  direct  the  sound  into  the  mouth,  and  at  other  times  allow  a 
portion  or  all  the  sound  to  pass  through  the  nose.  It  is  under 
such  circumstances  that  all  metallic  obturators,  no  matter  how 
ingeniously  constructed,  are  not  only  clumsy  and  troublesome 
contrivances,  but  ineffectual  to  accomplish  articulation.  They 
serve  only  to  plug  the  nares,  Avhich  the  patients  might  do  for 
themselves  by  stopping  the  nose  with  cotton,  or  by  any  other 
simple  means,  and  still  be  as  far  from  any  material  improvement 
of  speech  as  ever.  Metallic  obturators  may  make  speech  easier 
for  the  patient,  but  rarely  any  more  distinct.  An  elastic  flexible 
artificial  velum,  to  replace  the  lost  organ,  is  the  only  mechanical 
contrivance  which  can  assist  in  producing  this  desirable  result. 
To  Stearns  great  credit  is,  undoubtedly,  due  for  having  demon- 
strated, by  his  experiments,  that  an  artificial  velum  can  be  con- 
structed, which  may  be  worn  in  the  fissure  without  discomfort, 
and  be  made  available  for  accomplishing  perfect  speech.  But 
to  Dr.  Kingsley  is  certainly  due  the  credit  of  having  taken  up 
the  matter  where  Dr.  Stearns  seems  to  have  left  off";  to  have 
made  such  improvements  in  the  perfection  and  simplicity  of  the 
instrument,  and  to  have  reduced  the  manner  of  accomplishing 
it  to  such  system,  as  to  leave  success  no  longer  problematical 
and  dependent  upon  chance,  but  a  certainty,  dependent  only 
upon  the  skill  of  the  operator.  We  can  speak  from  our  own 
knowledge,  having  seen  some  of  his  cases  ;  one,  in  particular, 
which  presented  the  apparently  insurmountable  obstacle  of  the 


8-44      DR.  kingsley's  artificial  velum  and  palate. 

entire  loss  of  the  natural  teeth,  not  a  tooth  left  from  which  any 
support  could  be  obtained  for  such  an  appliance ;  and  yet,  in 
this  case,  the  velum,  by  the  beauty  of  its  adaptation,  was  not 
only  self-supporting,  but  actually  sustained  an  entire  upper  set 
of  teeth  with  as  much  firmness  as  is  ordinarily  obtained  from 
spiral  springs. 

The  cases  of  congenital  fissure  of  the  palate  most  commonly 
met  with  are  when  the  fissure,  commencing  with  a  division  of  the 
uvula,  extends  forward  through  the  soft  palate,  terminating  at 
about  the  centre  of  the  arch,  or  at  the  base  of  the  alveolar 
ridge.  Although  they  differ  materially  one  from  another  in  their 
outline,  there  are  certain  general  characteristics  w^hich  are  com- 
mon to  them  all,  and  which  can  be  made  available  for  that  sup- 
port of  the  artificial  palate  or  velum,  upon  Avhich  its  success  de- 
pends; so  much  so,  that  the  ingenious  and  skillful  dentist  can 
adapt  the  same  principle  in  the  construction  of  the  instrument 
to  almost  any  case,  even  if  the  fissure  extends  entirely  through 
the  alveolar  ridge  in  front.  A  prominent  and  important  charac- 
teristic is  a. recess,  beginning  at  the  lower  end  of  the  remnant 
of  the  velum,  and  extending  up  behind  it  on  either  side,  until  it 
terminates  in  the  nares,  or,  in  the  absence  of  the  septum,  uniting 
in  front  of  the  apex  of  the  fissure.  In  some  cases,  the  septum 
is  united  to  one  plate  of  the  maxillary  bone,  extends  a  little 
distance  back  of  the  apex  of  the  fissure  and  forms  on  one 
side  its  boundary.  In  such  cases,  however,  it  ends  abruptly, 
and  the  recess  behind  the  edge  of  the  fissure  as  abruptly  com- 
mences. It  will  thus  be  seen  that  the  fissure  presents  somewhat 
the  character  of  an  opening  through  a  curtain  or  roof,  and  which 
can  be  taken  hold  of  on  both  sides  nearly  or  quite  around  its 
entire  distance.  It  is  essential  that  a  knowledge  should  be  gain- 
ed of  the  conformation  of  this  recess  behind  the  remnant  of  the 
soft  palate,  back  ;  behind  and  above  the  bone,  forward ;  and  at 
the  apex. 

These  parts  are  out  of  sight,  but  a  pretty  accurate  knowledge 
of  their  form  and  relation  to  each  other  must  be  obtained.  This 
brings  us  to  a  consideration  of  the  most  important  part  of  the 
whole  operation,  viz.,  the  getting  of  an  accurate  impression  of 
the  fissure  throughout  its  entire  length,  of  all  the  parts  exposed, 
behind  and  above  it,  and  of  all  that  portion  of  the  roof  of  the 


DR.    KINGSLEY's   artificial  VELUM    AND    PALATE.         845 

mouth  and  the  anterior  face  of  the  soft  palate  contiguous  to  it. 
An  impression  can  be  taken  by  a  skillful  operator  of  all  these 
contiguous  parts,  reaching  even  some  little  distance  below  the 
remnant  of  the  uvula,  and  representing  the  whole  chamber  and 
walls  of  the  pharynx.  We  have  seen  an  impression  taken  by  Dr. 
Kingsley,  which  reached  full  three-fourths  of  an  inch  below  the 
uvula,  and  representing  fully  the  chamber  and  posterior  walls  of 
the  pharynx.  To  do  this  successfully,  and  get  a  representation 
of  the  soft  and  muscular  parts  in  their  quiet  state,  requires  the 
utmost  exercise  of  patience  and  perseverance,  skill,  gentleness 
and  firmness  on  the  part  of  the  operator;  and,  on  the  part  of  the 
patient,  perfect  confidence,  and  that  cessation  of  muscular  move- 
ment which  can  be  gained  by  training  or  handling  the  parts. 

In  taking  an  impression,  plaster  of  paris  as  is  used  for  other 
operations  in  dentistry,  is  by  far  the  best  substance  that  can  be  em- 
ployed. When  properly  mixed,  it  will  not  disturl)  in  the  slightest 
degree  the  most  delicate  structures,  which  can  be  said  of  no 
other  substance  now  used  for  such  a  purpose.  Ordinarily  several 
sittings  will  be  required  before  a  full  impression  of  all  these  parts, 
at  once,  can  be  obtained.  Unless  the  soft  or  muscular  parts 
have  been  trained  to  quiet  by  handling,  they  must  be  educated 
to  bear  the  presence  of  an  impression.  This  may  be  accom- 
plished partly  by  the  patient  using  a  bit  of  soft  sponge  attached 
to  the  end  of  a  stick,  and  bathing  the  parts  with  some  mild 
astringent  Avash  several  times  a  day.  It  is  also  well  to  take  a 
a  partial  impression,  say  such  as  would  be  required  for  an  upper 
set  of  teeth,  and  at  the  next  sitting  gradually  encroach  upon 
the  delicate  ground.  In  this  way  a  full  impression  may  be 
taken  after  a  few  sittings  with  no  more  apparent  inconvenience 
to  the  patient  than  the  first  or  partial  one.  It  will  facilitate  the 
success  of  matters  if  from  the  first  impression  a  model  be  made 
and  an  impression  cup  struck  up,  conforming  somewhat  to  the 
opening,  and  reaching  far  enough  back  to  support  the  plaster  from 
dropping  in  the  throat.  It  will  also  be  necessary  to  remove  the 
plaster  as  soon  as  it  has  stiff"ened  enough  to  keep  its  form,  as  it 
will  be  found  dovetailed  above  the  bone  at  the  apex  of  the  fissure, 
and  if  allowed  to  remain  until  hard,  cauld  not  be  removed  with- 
out injury  to  the  surrounding  structures.  By  removing  before 
it  has  hardened,  it  will  break  on  a  line  with  the  fissure,  and  the 


84(3  DR.    KlN(iSLEY"S    ARTIFICIAL   VELUM    AND    PALATE. 

piece  above  may  be  slipped  back  and  taken  out  at  leisure.  It 
will  also  tend  to  ensure  the  success  of  the  impression,  to  place 
the  soft  plaster  fir.st  above  the  opening  at  the  apex  with  a  small 
curved  spatula,  and  then  to  carry  the  plaster  in  the  impression 
cup  immediately  against  it.  Success  will  be  also  dependent  very 
much  upon  the  skill  of  the  operator  in  managing  his  plaster, 
mixing  it  to  the  proper  consistency,  and  using,  and  removing  it.  at 
just  the  right  moment. 

The  plaster  model  had  better  be  made  so  that  the  part  of 
the  model  which  represents  the  posterior  nares  may  be  removed 
from  the  remainder,  so  as  to  bring  the  parts  above  the  fissure 
more  immediately  under  inspection.  This  model  may  be  com- 
pared with  the  natural  parts  in  their  quiet  state,  to  ascertain  its 
correctness.  Trifling  alterations  of  form  about  the  remnant  of 
the  uvula  may  be  made  on  the  model,  but  if  great  discrepancies 
apj)ear,  a  new  impression  must  be  taken.  On  this  plaster  model 
may  be  adapted  an  artificial  velum  of  any  plastic  substance  ; 
sheet  gutta  percha  is  very  good,  (consult  Figs.  312,  313,  page 
849  for  a  better  understanding  of  the  following  description.) 

Let  it  reach  across  the  fissure,  extending  from  the  apex,  follow- 
ing the  curve  of  the  soft  palate  down  past  the  uvula,  and  of  suflSci- 
ent  length  to  reach  the  pharynx  when  contracted  upon  it,  carry 
a  wing  of  it  behind  the  edges  of  the  fissure  to  the  full  depth  of 
the  recess,  along  the  whole  length,  and  another  wing  forward, 
partially  covering  the  anterior  portion  of  the  soft  palate,  like  a 
flange  running  from  a  point  near  the  uvula  clear  around  to  the 
opposite  point,  E.  This  flange  to  extend  about  half  the  distance 
from  the  edge  of  the  fissure,  to  the  base  of  the  teeth.  The  wings 
and  flange  to  be  modeled  about  the  thickness  of  an  ordinary 
card  ;  the  body  reaching  across  the  fissure,  double  that  thick- 
ness :  and  the  forward  part  resting  upon  the  top  of  the  bone  D, 
D,  thickened  up  three  or  four  times  as  much  according  to  space, 
as  on  the  firmness  and  accurate  adaptation  of  the  instrument  on 
this  ledge  of  bone  at  the  apex  depends  a  great  deal  of  its  security. 
Model  the  whole  so  as  to  restore  as  much  as  possible  a  natural 
form  to  the  dome  of  the  mouth.  AVe  have  now  an  artificial  velum 
which  as  to  form,  simply  to  fill  the  cavity,  is  all  that  is  necessary  ; 
but  which,  to  be  made  of  use,  must  be  changed  for  an  elastic  and 
durable  material.      It  must  provide  for  contraction,  as  when  the 


DR.  kixosley's  artificial  vklum  and  palate.       847 

muscles  operate  against  it ;  it  must  be  flexible,  easily  moved, 
delicate,  capalile  of  no  injury  to  the  parts  with  whicb  it  is  in  con- 
tact, also  elastic,  falling  immediately  into  its  natural  place  when 
the  pressure  is  removed.  It  must  also  be  provided  with  means 
to  hold  it  in  its  place.  To  secure  all  the  above  mentioned  quali- 
ties, elastic  vulcanized  rubber  is  the  only  material  now  known  to 
the  profession  which  will  answer  the  purpose.  Properly  prepared, 
it  possesses  the  inherent  quality  of  instantly  returning  to  its  place 
when  pres.sure  is  removed  ;  but  to  provide  for  its  contraction 
upon  itself  when  the  muscles  act  in  that  direction  requires  a 
mechanical  arrangement  of  its. parts:  the  <»nly  way  seems  to  be 
to  form  it  in  leaves  or  lamirife  which  shall  overlap  and  slide  upon 
each  other  under  pressure. 

Stearns'  vehnn  was  formed  of  three  pieces,  being  slit  uj)  froui 
the  posterior  end  nearly  to  the  apex,  and  a  flap  covering  the  slit, 
under  which  the  two  halves  slide  past  each  other.  Of  it  he  says. 
(Vide  Vulcanite,  vol.  1,  page  78,)  "I  wish  here  to  be  under- 
stood as  saying  in  exact  terms,  that  T  consider  the  slit  and  open- 
ing through  the  centre  and  its  closure  by  a  sort  of  valve  on  the 
anterior  surface,  as  an  essential  feature  of  all  artificial  vela, 
and  again,  "  I  am  confident  that  this  one  feature  will  be  preserved 
in  all  successful  obturators."  But  later  developments  have 
proved  how-  unw^ise  it  was  to  so  narrowly  limit  the  perfection  to 
which  a  mechanical  arrangement  may  be  carried.  It  is  not  at 
Jill  necessary,  that  the  instrument  should  be  composed  of  three 
pieces;  an  equally  effective,  and  in  some  cases  a  superior  velum, 
may  be  made  of  only  two  pieces ;  hence,  it  is  merely  a  matter  of 
convenience,  not  an  essential  feature.  The  process  to  be  followi-d 
in  making  a  mould  in  which  to  vulcanize  an  elastic-rubber  dupli- 
cate  of  the  model  artificial  velum,  already  obtained,  is  an  ex- 
ceedingly intricate  one. 

It  will  be  utterly  impossible  to  give  detailed  specific  direction-* 
for  makino;  the  mould.  General  directions  only  can  he  given, 
and  to  the  skill  and  in-ienuitv  of  the  dentist,  must  be  left  th.- 
carrying  out  to  perfection  of  many  of  the  minor  details.  To  any 
one  who  understands  the  sculptor's  art  of  piece-moulding  or 
making  a  mould  in  sections,  it  will  be  comparatively  ea.sy. 

Tiie  great  point  to  be  gained,  is  to  obtain  an  elastic  dui)licat  • 
of  the  model  velum,  making  such  sejiarations  in  it  a<^  will  proviile 


848 


DK.    KINGSLEY'S    artificial   VELUM    AND    PALATE. 


f(ir  its  contraction.  For  such  purpose,  plaster  of  which  a  mould 
ini<'ht  be  easily  made,  will  not  answer.  An  elastic  velum  made 
in  a  plaster  mould  presents  a  surface  covered  with  little  excres- 
cences which  cannot  be  polished  oif,  and  which  seriousl}^  impair 
its  efficiency.  Type  metal  is  a  very  excellent  material,  being 
easily  worked,  presenting  a  clean  fine  surface,  and  making  a 
durable  mould,  from  Avhich  any  number  of  vela  may  be  obtained. 
The  mould  should  consist  of  six  or  seven  prominent  pieces, 
which  may  be  first  made  of  plaster,  moulded  in  sand,  and  dupli- 
cated in  metal.  The  division  of  the  separate  parts  of  the  velum 
takes  place  after  it  is  packed  in  the  mould,  and  before  vulcani- 
zing. A  very  good  plan  is  to  make  a  trial  piece,  by  vulcanizing 
an  elastic  velum  in  a  plaster  mould,  (without  any  attempt  to 
make  it  in  divisions,)  which  can  be  placed  in  the  fissure  to  ascer- 
tain the  correctness  of  the  adaptation,  always  preserving  intact 
the  original  model-velum.  If  the  trial  piece  is  not  accurate  in 
its  adaptation,  the  model  velum  may  be  correspondingly  altered. 
The  model  itself  being  rigid  cannot  be  inserted  in  the  fissure  for 
trial,   hence   the  necessity  for  an  elastic   duplicate  trial   piece. 

This  course,  if  followed  before 
Fig.  ::n.  ' 

the   permanent   metal   mould 

is  made,  may  "save  many 
tedious  alterations.  A  care- 
ful examination  of  the  accom- 
j)anying  illustrations  will 
convey  to  the  reader  all  the 
additional  explanations  which 
can  be  given  in  this  article. 

Fig.  311  represents  a 
plaster  model  of  the  jaw,  of  a 
patient  aged  16,  with  fissure 
•'f  the  palate.  The  letters  I,  I.  show  the  beginning  of  the 
fissure  with  a  division  of  the  uvula.  The  horizontal  line  around 
tlu-  nuidci,  and  similar  perpendicular  lines  on  the  anterior  and 
jtosterior  parts,  indicate  the  divisions,  into  which  the  model  may 
be  made  for  convenience. 

Fig.  312.  An  artificial  velum  or  palate  made  in  two  divisions, 
which  overlap  and  slide  upon  each  othei-.  The  letters  A,  A,  in- 
dicate the  posterior  ends  of  these  leaves.     To  support  the  lower 


DR.    KINGSLEY's    artificial    VELUM    AND    PALATE.  849 

leaf  in  a  horizontal  position,  the  double  arched  bow  B.  is  attach- 
ed, as   represented,   to  the  sides  of   the 

.  ,  ,.      ,  Fig.  312. 

instrument,  with  a  perpendicular  connec- 
tion passing  through  the  slot  C,  in  the 

upper  leaf,  and  attached  to  and  support-  j^^  ^^^^^  "J&s^^a 
ing  the  lower  leaf,  without  in  any  way 
impairing  the  contraction  of  the  instru- 
ment. This  bow  is  of  the  same  material  as 
the  body  of  the  velum,  and  continuous  with  it,  not  made  sepa- 
rately and  attached  to  it.  The  two  projections  marked  D,  D, 
pass  above  and  rest  upon  the  bone  at  the  sides,  and  in  front  of 
the  apex  of  the  fissure.  E  shows  one  of  the  wings,  which 
partially  covers  the  anterior  face  of  the  soft  palate.  The  reader 
will  bear  in  mind  that  these  engravings  are  reduced   nearly  one 

half;    so    that    artificial    vela    and    the  „ 

'         _  _  Fig.  313. 

moulds  in  which  they  are  made,  are 
about  twice  the  size  represented  in  these 
figures. 

Fig.  31-3  represents  a  velum  of  three 
divisions.  The  bod}^  of  the  velum  is 
separated  from  the  posterior  end  to  near 
the  apex  of  the  fissure,  and  the  flap,  F,  covers  the  slit.  The  flap 
is  supported  on  the  other  side,  by  a  double  arched  bow  and  at- 
tachment, as  in  Fig.  312.  The  same  letters  refer  to  the  same 
points  in  both  drawings. 

Fig.  314  shows  the  type  metal  mould.  This  mould  is  for 
packing  and  vulcanizing  an  elastic  velum  of  three  divisions.  No. 
1.  Main  piece  or  base  of  mould.  The  small  block,  G,  is  adapted 
to  the  mortise  in  the  base  also  marked  G.  When  in  position, 
there  is  an  opening  through  the  centre  of  the  block,  and  a  groove 
from  this  opening  passing  out  each  side  from  under  the  block. 
This  groove  provides  for  forming  the  double  arched  bow  as  seen 
in  Fig.  312.  The  pin,  IT,  provides  for  a  hole  in  the  velum  by 
which  it  is  connected  Avith  a  plate  in  the  mouth,  which  assists  in 
its  support.  No.  2.  Two  side  blocks.  No.  3.  Top  piece  of  mould 
with  a  depression,  J,  to  form  the  flap  of  the  velum.  No.  4  is  used 
in  connection  with  No.  3,  to  mould  the  flap  separately,  and 
afterward  transfer  it  to  No.  1.  No.  5.  Top  piece  to  mould  ; 
but  without  do])ression  to  form  the  flap,  iis  in  No.  3. 


SoO         DH.    KINGSLKY'ri    AKTIFK'I.AL    VKLUM    AND    PALA'J 


TE. 


Fig.  ;^14. 


N?   I. 


DR.    KINGSI>EY  S    ARTIFICIAL   VELUM    AND    PALATE. 


851 


To  jiack  a  velum,  elastic  rubber,  peculiarly  prepared  for  this 
purpose  must  be  used.  Cover  with  a  solution  of  soap,  all  that 
part  of  the  mould  which  will 
come  in  contact  with  the  rub- 
ber, which  will  prevent  the 
rubber  from  sticking  to  it 
when  vulcanized.  Put  the 
side  blocks,  No.  2,  in  place, 
and  pack  the  space  with  rub- 
ber until  filled.  Put  on  top 
piece  No.  5,  and  warm  the 
mould,  and  press  it  together 
with  strong  clamps.  Cool 
off  the  mould  and  open  ;  if 
imperfectly  packed,  add  more 
and  press  again.  In  the 
meantime  pack  the  depres- 
sion, J,  in  No.  3,  with  rubber,  | 
using  No.  4  to  pre?s  it  into 
shape.  Remove  top  piece  No. 
5  from  the  mould,  and  put  No. 
3  containing  the  flap  in  its  place,  previously  slitting  the  body  of 
the  velum,  from  the  posterior  end  to  near  the  apex,  and  put  a 
slip  of  paper  into  the  slit  to  prevent  a  union  in  vulcanizing. 
Put  also  a  piece  of  paper  under  the  flap  for  the  same  purpose, 
permitting  the  flap  to  unite  at  the  forward  end  with  the  body  of 
the  velum. 

Different  lubber  compositions  require  different  degrees  of  heat 
and  lengths  of  time  for  vulcanizing.  A  composition  used  for  this 
purpose  successfully,  has  required  four  hours  of  steam  heat,  run- 
ning gradually  from  230°,  and  ending  at  260°  Fahrenheit.  The 
attachment  to  keep  the  velum  in  position  in  the  mouth,  may  be 
very  simple.  If  the  adaptation  according  to  the  foregoing  metliod 
be  as  accurate  as  professional  skill  can  make  it,  the  velum  will 
only  reijuire  such  support  as  shall  prevent  its  inclination  to  slip 
down  the  throat.  In  ordinary  cases  where  a  portion  of  the 
natural  teeth  are  remaining,  a  plate  may  be  made  reaching  from 
the  molars  on  one  side  across  the  mouth,  to  the  molars  on  the 
other  side,  and  attaehed  with  clasps,  as  used   in  cases  of  partial 


"^h 


852         DR.    KINQSLEY  S    ARTIFICIAL   VELUM    AND    PALATE. 

sets  of  teeth.  Where  no  teeth  remain,  an  upper  artificial  set  may 
be  made  in  the  usual  manner.  In  either  case  all  the  attachment 
to  the  velum  necessary  is  such  as  will  keep  the  velum  closely  up 
to  the  apex  of  the  fissure,  without  straining  it  from  its  natural 
position,  and  yet  allowing  an  easy  lateral  motion.  A  method 
easy  of  accomplishment,  is  to  fit  a  gold  tube  with  an  opening  on 
one  side  through  its  entire  length,  to  the  hole  in  the  forward 
part  of  the  velum.  (Fig.  315,  No.  1.)  This  tube  may  be  secured 
in  its  place  by  any  means  which  will  keep  it  from 
turning  around.  To  the  posterior  part  of  the 
mouth  plate,  attach  an  upright  pin  of  the  size  of 
the  bore  of  the  tube,  and  to  the  upper  end  of  the 
pin  a  small  square  projection,  in  the  form  of  a 
key,  (Fig.  315,  No.  2.)  Arrange  the  parts,  when  adapted  to 
each  other,  so  that  the  key  will  pass  through  the  tube  and  turn 
around.  To  secure  the  velum  to  the  plate  beyond  any  possi- 
bility of  its  becoming  detached  when  m  situ,  the  key  must  turn 
in  a  diiferent  direction  from  the  slot  in  the  tube.  This  will  not 
of  course  prevent  the  velum  from  being  swung  around  on  this 
pivot  and  detached  at  pleasure,  when  out  of  the  mouth. 

To  put  this  somewhat  formidable  apparatus  into  its  place,  es- 
pecially when  united  to  an  upper  set  of  teeth,  would  seem  at  first 
sight  almost  impossible,  but  with  a  little  practice  there  is  no  diffi- 
culty. The  throat  has  already  been  educated  to  bear  the  pres- 
ence of  a  foreign  body,  and  by  carrying  the  velum  well  down 
the  throat  until  the  forward  projections  will  slip  behind  the  rem- 
nant of  the  soft  palate,  it  can  readily  be  brought  forward  and 
upward,  to  its  place  and  the  mouth  plate  secured. 

The  practical  advantages  resulting  from  the  wearing  of  such 
an  instrument,  have  already  been  demonstrated  by  years  of  ex- 
perience, beyond  any  ([uestion.  The  organs  of  speech  alone  are 
congenital;  speech  itself,  resulting  from  their  use,  a  faculty 
which  man  acquires  only  through  practice.  It  follows  then  that 
where  the  organs  of  speech  are  perfect,  the  only  limit  to  their 
exercise  is  the  capacity  and  perseverance  of  the  patient. 

^^  ith  a  fissure  ofthe  palate,  distinct  articulation  is  impossible. 
An  artificial  velum  replaces  as  far  as  practicable  by  mechanical 
means,  the  lost  organ,  and  renders  perfect  speech  posssible  just 
so  far  as  it  correctly  substitutes  the  natural   orcrans.     No  great 


ARTIFICIAL    PALATES    AND    OBTURATORS.  853 

or  iirimediate  improvement  is  observed,  nor  is  to  be  expected. 
From  long  practice,  even  in  the  youngest  patients  for  whom  it  is 
advisable  to  operate,  bad  habits  in  attempting  articulation  have 
been  formed  which  have  become  almost  permanent;  these  must 
be  broken  up  and,  in  a  sense,  the  patient  must  begin  anew  to  learn 
to  talk.  It  will  be  readily  seen  then  that  the  age  of  the  patient 
at  the  time  of  the  operation  has  an  important  influence  on  the 
final  success.  In  young  persons,  with  sufficient  sensitiveness  to 
the  defect,  to  impel  them  to  perseverance,  and  with  such  sugges- 
tions and  instruction  as  may  be  of  assistance,  a  few  years  may 
be  expected  to  develop  such  improvements  as  shall  entirely  con- 
ceal the  defect  from  the  ordinary  observer ;  and  in  some  cases 
this  has  already  been  accomplished  in  a  much  less  time. 

In  persons  more  advanced  in  life,  bad  habits  are  more  firmly 
fixed,  and  a  longer  time  will  be  required,  and  it  is  not  improbable 
that  certain  peculiarities  might  never  be  overcome.  In  all  ordi- 
nary cases,  a  well  adapted  artificial  velum  presents  to  the  eye 
of  the  physiologist  as  much  perfection  in  its  movements,  as  it 
would  seem  possible  to  attain  in  a  mechanical  contrivance.  It  is 
capable  of  being  raised,  depressed,  and  contracted,  at  will,  by 
the  power  of  the  muscle  in  the  remnant  of  the  natural  velum  ;  in 
short,  performing  to  all  appearances,  all  the  functions  of  the 
natural  palate. 

ARTIFICIAL  PALATES  AND  OBTURATORS,  COMPLICATED  WITH 

ARTIFICIAL  TEETH, 

When  an  imperfection  of  the  palate,  whether  the  result 
of  malformation  or  accident,  is  accompanied  by  the  loss  of 
one  or  more  teeth,  and  especially  from  the  anterior  part  of 
the  mouth,  the  plate  which  is  employed  for  remedying  the 
former  should  be  so  constructed  as  to  serve  as  a  base  for 
a  substitute  for  the  latter.  The  idea  of  complicating  a  i)alate- 
plate  with  artificial  teeth,  as  the  author  has  stated  in  another 
place,  originated  with  Fauchard.  When  a  palatine  obturator 
and  artificial  teeth  are  to  be  applied  at  the  same  time,  they  may 
be  connected,  and  the  piece  made  to  answer  an  excellent  pur- 
pose, provided  there  be  healthy  and  natural  teeth  in  the  upper 
jaw  to  sustain  it. 


h.'>4 


ARTIFICIAL    PALATES    AND    OBTURATORS. 


It  the  construction  of  an  artificial  palate  or  obturator,  to 
which  artificial  lootli  are  to  be  attached,  a  gold  plate  of  the 
proper  size  shonld  be  fitted  to  all  that  portion  of  the  vault  of  tlie 
pahite  anil  alveohu'  ridge  which   is   to   be   covered  by  it,  with  a 

lateral  branch  on  each  side  ex- 
^"'-  ^^^-  tending    to  the   first  molar,  or 

the  tooth  to  which  it  is  to  be 
clasped.  To  these,  clasps  should 
be  sohlered,  and  afterward  arti- 
ficial teeth  fitted  and  secured 
in  tlie  manner  described  in  Part 
Sixth  of  this  work.  If,  how- 
ever, the  upper  surfice  of  the 
plate  is  to  be  surmounted  with 
a  drum  or  air-chamber,  this 
sliould  be  done  before  tlie  teeth 
are  attached  to  it.  In  Fig.  oltJ 
may  be  seen  the  engraving  of  a  simple  palate-phite  or  obturator, 
with  the  central  and  lateral  incisors  attached  to  it. 

AVhen  the  teeth  have  all  been  lost  on  one  side  of  the  mouth, 
or  are  too  mucli  decayed  to  serve  as  a  support  for  an  obturator, 

either  with  or  without  artifi- 
ficial  teeth,  the  plate  may  be 
constructed  with  two  branches 
upon  the  other  side,  if  there 
be  two  healthy  and  firmly  ar- 
ticulated teeth,  to  which  clasps 
can  be  applied.  A  piece  ap- 
plied in  this  manner,  in  con- 
nection with  nine  artificial 
teeth,  namely,  the  four  inci- 
sors, two  cuspids,  two  bicus- 
pids and  one  molar,  is  shown 
in  Fig.  317.  The  clasps,  as 
may  be  perceived  by  the  cut, 
;'ie  mtended  for  a  second  bicuspid  and  second  molar.  Although 
the  molars  on  the  opposite  side  of  the  jaw  were  absent,  it  was 
not  deemed  prudent  to  increase  the  weight  of  the  piece  by  at- 
taching more  than  nine  artificial  teeth  to  the  plate. 


ARTIFICIAL    PALATES    AND    OBTURATORS. 


855 


Fig.   -MS. 


An  artificial  palate,  complicated  with  ten  artificial  teeth, 
namely,  the  central  and  lateral  incisors,  the  cuspids,  the  first 
bicuspid  of  the  left  side,  tiie 
first  and  second  of  the  right,  as 
well  as  the  first  molar,  is  repre- 
sented in  Fig.  318.  The  clasps, 
as  maybe  seen,  are  for  the  first 
molar  of  the  left  side  and  the 
second  of  the  right.  The  open- 
ing in  the  palate  to  be  covered 
by  the  plate,  in  this  case,  ex- 
tended from  the  alveolar  border 
backward  a  little  more  than  an 
inch,  and  was  about  seven- 
eigliths  of  an  inch  in  width. 

The  functions  of  mastication,  deglutition  and  speech,  which 
were  all  very  greatly  impaired  by  the  opening  in  the  palate  and 
loss  of  so  many  of  the  teeth,  were,  in  a  great  degree,  restored 
by  the  piece  here  represented. 


The  author  would  here  refer  to  an  obturator,  complicated  witli 
artificial  teeth,  constructed  by  Mr.  Warren  Rowell,  of  New  York. 
The  great  difficulty  to  be  overcome  in  this  case,  according 
to  report  made  of  it  by  Dr.  Griscom,*  was  the  want  of  teeth  in 
the  upper  jaw  to  sustain  it,  and  the  great  size  of  tlie  opening  in 
the  palate,  the  vomer  and  turbinated  l)ones  having  been  <le- 
stroyed.  Upon  examination,  however,  iMr.  Rowell  found  that 
the  posterior  portion  of  the  palatine  apertuie  was  formed,  '"to 
a  consideralde  extent,  of  a  semi-cartilaginous  substance,  possess- 
ing sufficient  elasticity  to  allow  a  larger  body  than  the  opening 
to  be  pushed  up  through  it,  and  that  when  so  forced  up,  it  would 
be  supported  above  the  aperture  by  the  edge  returning  to  it^ 
original  position."  This,  he  hojjcd,  would  support  a  light 
plate,  if  the  obturator  could  be  so  shaped  as  to  rest  upon  the 
cartilaginous  led";e,  after  it  was  introduced. 

Without  ([noting  the  description  which  is  given  of  his  method 
of  procedure,  it  will  be  sufficient  to  state,  that  the  obturator 
which  he  constructed  consisted  of  a  plate  larger  than  the  open- 


New  Y"ik  Journ'il  of  Medicine,  vol.  viii,  No.  2.'J,  p.  187. 


85G 


ARTIFICIAL    PALATES    AND    OBTURATORS. 


iiM'  ill  the  palate,  and  covering  the  anterior  part  of  the  alveolar 
rid'^e,  to  which  artificial  teeth  were  attached,  and  an  irregularly 
shaped  drum  or  air  chamber,  larger  above  than  below,  where  it 
was  connected  with  the  palate  plate.  The  neck  of  this  bulb  or 
drum  is  of  the  exact  size  of  the  opening  in  the  palate,  and  the 
upper  part  or  summit  has  several  depressions,  which  correspond 
with  the  irregular  surfaces  of  the  remainino;  nasal  bones. 


Fig.  319. 


Fig.  320. 


The  anterior  part  of  the  palate  plate,  to  which  the  teeth  are 
attached,  as  may  be  seen  in  Fig.  319,  is  composed  of  two  plates, 
to  compensate  by  its  thickness  for  the  deficiency  of  the  alveolar 
ridge.  The  drum  is  seen  rising  from  the  palate  plate,  to  which 
it  is  soldered.  In  Fig.  320  is  represented  a  lateral  view  of  the 
piece.  The  palate  plate  and  drum  are  composed  of  fine  gold, 
and  made  very  light. 

At  the  time  Mr.  Rowell  constructed  this  obturator,  we  are 
assured,  by  Dr.  Griscom,  he  had  never  heard  of  nor  seen  "  De- 
labarre's  proposed  operation,"  so  that  it  would  seem  that  the 
obturator  which  he  constructed  was  original  with  himself.  We 
are  also  informed  that  it  has  been  worn  for  six  years  (1841  to 
1847),  without  causing  any  appreciable  increase  in  the  size  of 
the  opening.  That  this,  however,  will  ultimately  be  the  case, 
we  think  there  can  bo  no  (question. 

Dr.  flutter  gives  an  engraving  of  an  artificial  palate,  compli- 
cated with  several  artificial  teeth  and  a  metallic  velum  connected 
with  the  i)alate  by  means  of  a  hinge,  constructed  by  Mr.  Neil,  a 
dentist,  of  Philadelphia,  which  is  represented  as  having  an- 
swered an  excellent  purpose.*  It  is  difficult  to  conceive,  how- 
ever, how  a  gold  plate  of  an  oval  shape  could  be  luade  to  perform 


*  Vide  Listen's  and  Miitter's  Surgery. 


ARTIFICIAL    PALATES    AND    OBTURATORS.  857 

the  functions  of  the  velum  pahiti.  So  far  as  an  imperfection  in 
the  hard  palate  is  concerned,  the  evil,  we  know,  may  be  remedied 
by  covering  the  opening  with  a  metallic  plate,  but  the  loss  of  the 
soft  palate  cannot  be  replaced  with  any  hard  unyielding  material, 
so  as  to  restore  the  functions  of  the  natural  parts. 

The  most  complicated  and,  at  the  same  time,  ingenious  piece 
of  mechanism,  of  which  we  have  ever  heard,  for  replacing  the 
loss  of  the  entire  palate,  including  the  velum  and  nearly  all  the 
teeth  of  the  upper  jaw,  was  invented  by  M.  Dclabarre;  but  in 
consequence  of  its  weight,  from  the  amount  of  material  in  it, 
as  well  as  the  complicated  structure  of  the  instrument,  it  failed 
to  realize  tlie  sanguine  expectations  of  the  inventor,  although 
he  states  that  it  fully  answered  the  purpose  for  which  it  was 
designed.  Subsequent  experiments,  however,  have  been  less 
successful,  and  as  this  method  of  constructing  artificial  palates 
has  long  since  been  abandoned,  we  do  not  think  it  necessary  to 
quote  the  description  which  he  has  given  of  it. 

Instead,  therefore,  of  employing  this  complicated  instrument, 
a  simple  palate  plate,  with  a  velum  like  the  one  constructed  by 
Mr.  Stearns,  or  that  made  by  Dr.  Kingsley,  or  with  Hullihen's 
or  Blandy's  valve,  and  having  artificial  teeth  attached  to  it,  will 
be  found  to  answer  a  much  better  purpose,  in  cases  such  as  that 
for  which  M.  Delabarre's  complicated  piece  of  mechanism  was 
prepared.  As  it  is  not  probable  that  such  an  appliance  will  ever 
be  constructed  again,  we  do  not  deem  it  necessary  even  to  copy 
the  engraving  furnished  by  the  author. 

M.  Desirabode  proposes  a  kind  of  platina  obturator  for  con- 
genital fissure  of  the  palate,  by  which  he  thinks  the  sides  of  the 
alveolar  border  may  be  so  approximated  as  to  favor  the  union  of 
the  divided  parts.  It  consists  of  a  platina  plate  fitted  to  the 
vault  of  the  palate  and  fastened  to  the  teeth  by  means  of  three 
crotchets  (clasps),  soldered  to  each  side,  so  as  to  cap  the  canine 
teeth,  the  bicuspids,  and  tWo  of  the  molar  teeth,  bent  upon  the 
alveolar  border,  in  such  a  manner  as  to  maintain  the  whole 
pressure.  After  the  plate,  with  these  appendages,  has  been 
well  adapted,  it  is  divided  from  before  backward  along  the 
median  line,  and  then  a  piece  is  removed  from  each  side,  so  that 
the  two  edges  may  be  separated  about  half  an  inch  from  each 
other.     The  two  half  plates  are  now  united  by  means  of  a  thick 


858  ARTIFICIAL    PALATES    AND    OBTUKATORS. 

and  resisting  band  of  caoutchouc,  made  fast  bj  riveting.  The 
plates,  thus  united,  form  a  smaller  obturator  than  the  plate 
before  it  was  divided,  so  that  it  can  only  be  applied  by  putting 
the  caoutchouc  upon  the  stretch,  which  is  effected  by  means  of 
two  stocks,  so  contrived  as  to  force  the  two  plates  asunder. 
After  ti^e  plate  is  properly  adjusted,  these  are  removed,  when, 
by  the  contraction  of  the  caoutchouc,  the  sides  of  the  alveolar 
border  are  gradually  made  to  approach  other. 

It  sometimes  happens  that  an  imperfection  of  the  palate  is 
accompanied  by  an  opening  into  the  maxillary  sinus.  In  this 
case,  the  palatine  plate  should  be  large  enough  to  close  both 
openings,  and  the  loss  of  the  alveolar  border  replaced  by  means 
of  a  raised  plate,  soldered  to  the  lower  surface  of  the  palate 
plate,  and  to  which  artificial  teeth  may  be  attached. 

Such  irregularities,  and  other  deficiencies  of  the  hard  parts 
can  be  most  perfectly  supplied  by  the  use  of  a  vulcanite  plate. 
The  more  pliant  forms  of  this  material  are  the  best  that  can  be 
used  for  artificial  vela  and  movable  plates ;  while  for  the  fixed 
base,  with  or  without  teeth,  no  better  material  can  be  found 
than  the  ordinary  dental  vulcanite,  which  is  peculiarly  adapted 
to  plates  of  such  very  irregular  surface  and  outline. 

In  conclusion,  it  only  remains' to  observe  that  the  same  atten- 
tion is  required  to  prevent  injury  to  the  natural  teeth,  which 
serve  as  a  support  to  an  artificial  palate  or  obturator,  as  to  those 
which  are  used  for  the  retention  of  dental  substitutes ;  and  as  full 
directions  have  already  been  given  upon  this  subject,  it  is  not 
necessary  to  repeat  them  here. 


INDEX. 


Abrasionof  the  teeth,  spontaneous 

Mechanical, 
Abyssinian  negroes,  teeth  of, 
Accretion  of  the  jaws. 
Acids  of  the  mouth, 
Adamantine  organ, 
Adhesion  of  gums  to  cheek,    . 
Adjustment  of  porcelain  teeth, 
Alveolar  abscess, 

Causes  of,     . 

Treatment  of,    . 

Arches,  shape  of,  . 
Alveolar  processes,  anatomy  of. 


408 

411 

.     257 

133-137. 

248-250 

.      113 

474 

.     687 

482 

.     484 

484 

.      130 

32,36 

Effect  of  mercury  on,    .       469,  492 

Exfoliation  of,  in  children,  471 

Causes  of,  .         .    '     .     472 

Symptoms  of,         .         .  471 

Treatment  of,     .         .         .     473 

Necrosis  and  exfoliation  of,        489 

Causes  and  treatment  of,   .     492 

Gradual  destruction  of,     .  493 

Causes  of,  ...     494 

Treatment  of,         .         .  495 

Tumors  of,  and  gums,  .         .     475 

Causes  of,      .         .         .  475 

Treatment  of,    .         .         .477 

Amalgam,         ....  270 

Antesthetic  agents,  use  of,    .    -     .     381 

Chloroform,       .         .         .  381 

Congelation,  .         .         .     383 

Ether,        .         .         .         .  381 

Electro-galvanism,         .      384-386 


Anatomy  and  physiology  of  the 

mouth,  .         .         .        27-116 
Anajmia,  color  of  gums  in,      .  213 

Antagonizing  models,  .         .         .     682 

For  block  teeth,         .         .  741 

Instruments  for,    .         .         .     686 
Antrum  Highmorianum,  anatomy  of,  33 

Diseases  of,  ....     499 
Arsenic  for  destroying  dental  pulp,   325 

Manner  of  applying  it,  .      326,  328 

A  remedy  for  odontalgia,  .  351 

Articulating  models,    .         .         .     682 
Articulators,  metallic,      .         .  686 

Plaster,  ....     683 

Artificial  teeth,         ...  592 

Retained  by  atmospheric  pres- 
sure, .         .         .  605.  717 


Artificial  teeth,  retained  by, 

Clasps,       .  .  .      603,  705 

Spiral  springs,       .  604, 699 

Different  methods  of  inserting,  60 1 

On  natural  roots.  .  601 

Substances  employed  for,      .     596 

Treatment  preparatory  for.         609 

With  gums  single  or  in  secdons.  702 

Artificial  palate^,      .         .         .  832 

With  velum  and  uvula,  .     836 

Mr.  Stearns',  .         .  837 

Dr.  HuUihens,  .         .         .     840 

Dr.  Kingsleys.       .  .  843 

Dr.  Blandys,     .         .      %.     842 

Arteries  of  the  mouth,     .         .      81-86 

Of  the  organs  of  deglutition,  84,  85 

84 

83 

84 

82 

85 

85 

85 

82 

85 

82 

82 

83 

86 

83 

83 

83 

84 

84 

84 

463 

464 

,717 

606 

727 

726 

721 


Of  insalivation 

Of  mastication. 
Of  the  pharynx. 
Of  prehension. 
Of  the  soft  palate. 
Of  the  tongue, 
Ranine,     . 
Artery,  external  carotid, 

Branches  of,  . 
Internal  carotid,    . 
Facial,       . 
Internal  maxillary. 

Branches  of. 

Inferior  dental,  . 

Superior  dental. 

Infra-orbital, 

Superior  palatine, 

Spheno-palatine, 
Temporal, 
Astringent  lotions  for  the  mouth, 

Authors  formula, 
Atmospheric  pressure,  .      605 

By  whom  first  used, 
Cleaveland's  cavity, 
Dwinelles  method,    . 
Size  and  shape  of  plate  for. 


Theory  of, 
Vacuum  cavity. 
Atrophy  of  the  teeth. 
First  variety, 
Second  variety, 
Third  variety. 
Singular  case  of, 
Causes  of, 
Treatment  of,   . 


606,  717-720 

.  724 

387-395 

.  389 

390 

.  391 

394 

.  392 

395 


8t)0 


INDEX. 


r,ackin<r  poriclain  teeth,       .          •  690 
How  to  proceed  when  alveo- 

hir  riilge  is  uneven,  .  744 
Bell,  researches  of  Mr.  T.,  .  101 
Berzelius'  analysis  of  dentine,  .  50 
Bicuspids,  manner  of  scpiiratinff  the,  261 
Block  teeth,  (see  Porcelain)  .  730 
Aluminous  and  silicious  ma- 
terials   730 

Attachment  of,  to  plate,      751,  777 

Coloring  materials,        .         .  732 

Recipes  for  body,      .         .  736 

For  tooth  enamel,      .         .  737 

For  gum  enamel,  .         .  739 

Blood,  importance  of  pure,           .  194 

Of  children,      .          .          .  224 

Blow  pipes,           ....  672 

Alcoholic,          .          .          .  674 

Elliot's  improved  self-acting,  675 

Hydrostatic,       ...  678 

Macoinber's,           .          .         .  679 

Parmly's  self-acting,          .  673 

Somcrby's  compound,   .          .  676 

Borax,  use  in  soldering,    .  670 

Glass  of,  how  made,      .          .  739 

Brush,  polishing,      .         .         .  696 

Building  on  the  whole  or  part  of 

the  crown  of  a  tooth,  338 

Utility  of,       ...          .  338 

Preparation  for,  .  .  339 
Process  of,    .                   .       340-342 

Dr.  Austen's  method,  343 

C. 

Carat  valuation  of  gold,       .  .     635 

Caries  of  the  teeth,  .  234-253 

Bew's  theory  of,  .  .  .  246 
Chemical  theory  of,  .         .  248 

Causes  of,  .  .  .  242-251 
Differences  in  liability  of  differ- 
ent teeth  to,  .  .  237-242 
Different  from  caries  of  bones,  233 
Fox  and  Bell's  theory  of,  .  239 
Indirect  causes  of,     .         .  250 

Liability  of  teeth  to,  .  .  237 
Lintot's  theory,  .         .  248 

Not  caused  by  inflammation,  244 
Prevention  of,  .         .  251 

Secret  development  of,  .  .  234 
Seldom  occurs  amongst  Indians,  247 
Tomes'  theory  of,  .  .  .  248 
Treatment  of,    .  .  252 

Vital  theory  of,     .  .       243-245 

Where  first  developed,       .  234 

Carueous  tubercle,       .         .         .127 
Cartilaginous  excrescences,      .  479 

Causes,  ....     480 

Casserian  ganglion,  .         .  88 

Cassius,  purple  powder  of,  .         .     734 
Catalan,  inclined  plane  of,  156 


PAilE 

Cattle,  teeth  of,    .         .         .         .     597 

Cavities  of  reserve,  .         .  104 

in  teeth,  filling,     .  .        287-309 

Instruments  for  forming,         27  J 

Manner  of  forming,    .  .      277 

Cavity,  vacuum,        .         .  718,724 

Abuses  of,     .         .         .         .729 

Size  of,  for  a  single  tooth,  728 

Theory  of,    .         .  .719 

Use  of,      ....  720 

With  valves,  .         .         .     726 

When  invented,         .         .  725 

Cementiim,  Anatomy  of,       .  54-56 

Chemical  analysis  of,  .  55 

Formation  of,         .  .  .116 

Lacuna;  of  the,  .  .  55 

Nasmyth's  opinion  of,    .  .        54 

Vitality  of,         .  .  .  56 

Ceylonese  furnace,        .  .     694 

Characteristics  of  the  teeth,  (see 

Physical  characteristics,)     183 
Cheek  and  tongue  holders,        .  307 

Cheoplastic  process,     .         .         .     783 
Chloride   of  zinc   for   destroying 

sensibility  of  dentine,     .     420 
Clasps,     .  .       '  .  .   603,  665,  705 

Application  of       .  .       709-716 

Fitting  to  tooth,         .  .  669 

Fogies  method  of  adjusting,      666 
Noble's  method,         .         .  667 

Prevention  of  injury  from,     .     708 
Thickness  of,     .  .  604, 665 

Teeth  suitable  for,  .         .     705 

Classification,     physiological,    of 

teeth,     .         .  .         .196 

Cleaveland's  air  chamber  plate,  727 

Coloring  materials  for  porcelain  teeth732 

Condensing  forceps,     .         .         .     302 

Condyloid  process,  .         .  37 

Constitution  influenced  by  regimen,  187 

Continuous  gum  work,  .  .      753 

Compared  with  blocks,      .  754 

Durability  of,  .  .  .      754 

Firing  and  baking,    .  .  759 

Materials  of,  ...      755 

Soldering,  .  .  .  758 

Convulsions  caused  by  teething,  .     122 

Copper,  pickle  for  dissolving,  .  696 

Use  of  in  solder,  .         .         .     642 

Use  of  in  plate,         .         .  632 

Corda  tympani,    ....        90 

Coronoid  process,    ...  37 

Counter-dies,        ....     660 

Crowded  teeth,         .  .  139,  140 

Correction  of,        .         ,      141,  142 

Crown,  artificial,  of  gold,  .  338 

Crucing  or  biscuiting  blocks,       .     746 

Crusta  petrosa,         ...  54 

Crystal  gold,         .  .  .  .267 

Filling  teeth  with,     .  .  331 

Instruments  used  for,    .         .     331 

Introducing  and  consolidating,  335 


INDEX. 


861 


D. 


Damp  residence,  effect  on  teeth,  211 
D'Areet's  nieral,  ....  270 
Deafness,  from  enlarged  tonsils,  74 

Deca.y  of  teeth,  (see  Caries,)         .     242 
Varieties  of,       .         .         .  235 

Differences  in  liability  of  dif- 
ferent teeth  to,   .  .  237 
Duval's  classification  of,         .     236 
Hereditary  predisposition  to,      241 
Decimal  valuation  of  gold,   .         .     635 
Defects  of  the  palate,       .         .          815 
Congenital,  .         .         .         .816 
Manner  of  remedying,        .  822 
Deformity  from  excessive  develop- 
ment of  lower  jaw,         .         .163 
Deglutition,  organs  of,      .         .     70-80 
Arteries  of  these  organs,         84-86 
Delabarre,  metallic  grate  of,     .  157 
Fusible  enamel  of,         .       704,  805 
Dental  groove,  primitive,          .  102 
Secondary,    .          .         .         .104 
Dental  pulp  and  periosteum,  dis- 
eases of,         .         .         .         .417 
Dental  substitutes,  .         .         .          596 
Dental  ligament,            ...       80 
Dentes  sapientia),  irregularity  of,      144 
Development  of,         .         .          107 
Dentifrices,           .         .         .         .252 
Dentine,  anatomy  of,         .         .     45,  51 
Chemical  analysis,         .          50,  51 
Development  or  formation  of,     108 
Areolar  stage,   .         .         .111 
Cellular,         .         .         .          Ill 
Linear,       .          .          .          .112 
Inter-tubular  structure,     .  48 
Microscopic  structure  of,  .     45-48 
Nerve  filaments  of,         .         48,  50 
Tubuli,  or  fibres  of,         .  .     45-47 
Vascularity  of,       .         .  50 
Dentist's  work  table  and  lathe,     .     689 
Dentition,  first,     .         .         .      117-124 
Critical  period  with  infants,    121 
Irritation  caused  by,      .          121 
Morl)id  effects,         .         121-124 
Second,          .         .         .      130, 133 
Connection  with  irregularity,  140 
Improper  interference  with,    138 
Method  of  directing.         138,143 
Third,  cases  of,     .          .         '.176 
Supposed  origin  of,        .          179 
Denuding  of  the  teeth,          .         .     404 
Desirabode's    fusible    enamel    for 

plates,    .         .         .         .704 
Development  of  milk  teeth,       .  08-1U8 
Progress  of,       .  101-l(i7 

Time  of  .  .  .  .108 
Deviation  of  teeth,  singular  cases  of,  168 
Dies  and  counter-dies,  .         .     65() 

Disease,  characteristic  of,         .  192 

Diseases  of  the  teeth,  .         .         .     231 


PAQK 

Diseases  of  the  alveolar  processes,  482 
Of  the  gums,           .         .     455-482 
Of  the  maxillary  sinus,     .  499 
Of  the  palate.         .         .         .  80<i 
Of  the  pulp  and  periosteum,  417 
Dislocation  of  lower  jaw,      .          .  439 
Disorganization  of  dental  pulp,  433 
Displacement  of  teeth,           .         .  496 
Drill  stocks,  Maynard's,    .          .  274 
Merry's,          •          .          .          .275 
McDowell's,      .         .         .  275 
Lewis's,          ....  275 
Dunning,  Dr.,  on  filling  pulp  cavi- 
ties,        321 

Dwinelle's  cavity  plate,    .         .  726 


E. 


Elevator, 374 

Klliot's  pivot  forceps,       .         .         617 

Empiricism  in  dentistry,       .         .     M4 

Enamel,  anatomy  of,         .         .      51-54 

Artificial  tooth  and  gum,      .     737 

Cells  discovered  by  Prof.  C. 

Johnston,  .  .  .48 
Chemical  analysis,  .  .  53,  54 
Denudation  of,  .  .  .  404 
Formation  of,     .         .  113-116 

Importance  of,        .  .        52.  255 

Membrane,   (Nasmyth's  )       51,115 
Microscopic  structure  of,        .       52 
Enameling  block  teeth,    .         .  747 

Continuous  gum  work,  .     760 

English   teeth,    how  attached   to 

plate,      .         •         .         .697 

Erosion  of  the  teeth,         .         .  388 

Excavators,  .         .         .      272,  276 

Excising  forceps,      .         .         .  612 

Exfoliation  of  alveoli,  .         .         .     471 

Exostosis  of  the  teeth,       .  398-401 

Exposed  nerve  of  tooth,        .         .     3 Id 

Extirpation  of,  .         .  322 

Filling  over,  •         .         .310 

Prevention  of,  .         .         .  315 

Treatment  of.         .  .  .316 

Extraction,  of  teeth,         .         .  355 

Hemorrhage  after,         .         .     378 

Instruments  employed  in,  359 

Rules  for,  in  first  dentition,  .     357 

In  second  dentition,      .  358 

Of  roots  of  teeth,  .     373 

Instruments  for,  .     374-378 

Of  temporary  teeth,  .         .  378 

Use  of  amusthetic  agents  in, .     381 

Eye  teeth,  (cuspids,)         .         •  57 


F. 

Face,  bones  of  the, 

Fangs  of  teeth,  (sec  Roots,) 


31-39 
40 


862 


INDEX. 


PAGE 

Fung  filling, 

318,330 

Author's  metho'l, 

327 

Foster's  experience  in.  . 

.     319 

Views  of, 

315 

Gorgas'  method,    . 

.     328 

Harwood's  method.  . 

323 

Maynfird's  method, 

.     ?.2Q 

Instruments  for. 

326 

Fauces,         .         .         .         . 

72 

Fifth  pair  of  nerves,  (Trigemini,)  87-93 

Files,  separating,      .         .  260, 262 

Carriers  for,  .  .  263 

Curved,  for  finishing  fillings,      309 

Maynard's  pattern,    .         .  309 

Filing  the  teeth.    .         .         .     254-263 

Cleanliness  necessary  after,       258 

Not  necessarily  injurious,      .     257 

Necessitv  of,      .         .         .  254 

Utility  of      .  .  .         .256 

When  improper,        .         .  256 

Filling  teeth,         .  .  .264 

Individual  cavities  in,         287-309 

Inferior  incisors  and  cuspids,     287 

Instruments  for,        .         .  281 

Lower  molars,  difficulties  of,     306 

Materials  for,         .       266-272,331 

Molars  and  bicuspids,  .         .     304 

(iver  exposed  pulp,  .         .         310 

Position  of  operator  whilst,  .     286 

Position  of  hand,  291,  292,  294,  298 

Preparation  of  cavity,    .         .     277 

Instruments  for,        .         .  272 

Pulp-cavity  and  roots  of  teeth,    318 

Sensitive  teeth,  .         .  265 

Special  directions  for,  .         .     277 

Superior  incisors  and  cuspids,  287 

.Molars  and  bicuspids,    .  296 

With  crystalline  or  sponge  gold.  331 

Finishing  process  for  gold  plate,       695 

Firing  and  baking  block  teeih,    .     747 

Fissure  of  Glasserius,       .         .  37 

Floss  silk  for  cleaning  the  teeth,       251 

Fogies  method  of  fitting  clasps.        666 

Follicles  of  developing  teeth,        .     103 

Forceps,  for  extraction  of  teeth,        363 

Uens  sapientia-,     .  .         .     syg 

Dentists  punch.        .         •  690 

For  removing  j»ivots,  .     617 

Hawks-bill.      .         .         .         scg 

Lower  molar,         .  •     366 

Incisor,  .  .  .  :^67 

Bicuspid 367 

.Manner  of  using,       .         .  370 

Sneli  s  improvements,  .         .     364 

Author's  improvement,  366 

Upper  molar,         .         .         .365 

Incisor  and  cuspids,  367 

Foster,    Dr.,    remarks    on    filling 

pulp  cavities,  .     .-^.Tg,  325 

Filling  over  the  nerve,         314  315 

Foot-lathes.     .         .'        .         .        '  688 

Fox.  Mr.,  bandage  for  lower  jaw,     l»;7 


FAOE 

Fractional  valuation  of  gold.  .  635 

Franklin's,   Dr.,   impression   cup,  644 

Safety  lamp,     .         .         .  672 

Vulcanizing  lamp,         .         .  769 

Vulcanizer,       .         .         .  770 

Fractures  of  the  teeth,           .         .  413 

Fraenum  of  the  lower  lip,           .  78 

l)f  the  upper  lip,  ...  78 

Of  the  tongue,           .         .  78 

Fungous  growth  of  dental   pulp,  435 

Furnace  and  blow-pipe,    •         .  677 


G. 


Gauge  plate,         ....     640 

Gelatinous  granular  substance,  104,  113 

Genial  processes,  ...       36 

Gilbert's  cavity  plate,      .         .  727 

Glands,  mucous,  .         .         .69 

Buccal,  molar  and  labial,  69 

Parotid,         ....       67 

Salivary,  ....      67-69 

Sublingual,  .         ,         .         .69 

Submaxillary,  ...  68 

Tonsil,  ....        74 

Gold,  alloying  of,     .         .         .  632 

Crystal  or  sponge  for  fillings,     331 

Injurious  effects  of  impure,        633 

Fillings,  manner  of  finishing,     284 

Instruments  for  introducing,  281 

Manner  of  introducing,  283 

Fineness  of,       .        ».         .  633 

Foil, 266 

Sponge  and  crystalline,    .  268 

Manner  of  refining  and  alloying,  624 
Plate,  manner  of  making,  637 

Refining,       .         .         .         .626 
Elliot's  method  of,  .  631 

Solder,  bow  made,         .         .     641 
Recipes  for,  .         .  6J2 

Gomphosis,  ....       61 

Good,  Dr.,  on  dentition,  .         .  121 

Goodsir,  researches  of,  .       101-108 

Grinding  apparatus,  hand  lathes.       615 
Foot  lathes,  .    '      .         .         .688 
Gums,  anatomy,       ...  79 

Acute  infiamraation  of,  .     457 

Adhesion  to  cheek,  .  474 

Appearance  of,  in  health,       .     207 
Dr.  Allen's  continuous,     .  753 

Atrophy  of,  ...      207 

General  health  indicated  by,      205 
Diseases  of,  .         .      455-481 

Causes  of,     .         .         .  456 

Dr.  Hunter's  continuous,        .     755 
Effects  of  mercury  on,      .  2\^2A0 
Chronic  inflammation  and  tu- 
mefaction of,     .  .  457-466 
Causes  of,          ...     460 
Treatment  of,         .         .  462 
Irritation  of,  causes,      .  205 


INDEX. 


863 


Gums, 

Insensibility  and  hardness  of,  79 

Internal  structure  of,         .  79 

Lancing,  in  first  dentition,  .     123 

Morbid  growth  of,     .         .  466 

Causes  of,  .         .         .  .     467 

Treatment  of,         .         .  468 

Mercurial  inflammation  of,  .     469 

Treatment  of,         .         .  470 

Ph}-sical  characteristics  of,  .     205 

Thickness  of,    .                   .  79 

Tumors  and  excrescences  of,  475 

Causes  of,      .         .         .  475 

Treatment  of,    .         .  .     477 

Ulceration  of,  in  children,  471 

Causes  of,           .         .  .472 

Treatment  of.         .         .  47:^ 

Gustator}-  nerve,  branches  of,  .       92 

Gutta-percha  for  temporary  fillings,  271 

For  impressions,   .         .  .     G45 

For  impression  cups,         .  649 

Used  in  bottom  of  cavities,  .     285 

H. 

Hand-lathes,         .         .         .         .615 
Harris'  mouth  wash,         .         .  464 

Head,  bones  of  the,      .         .         .       Mi' 
Hemorrhage  after  extraction,   .  378 

Cases  of,        ...         .     .379 
Hill's  stopping,  composition  of,  271 

Uses,     .  .  .       285,314,328 

Hook  for  extracting  roots,         .  374 

HuUihen's  screw  forceps,      .         .     376 
Human  teeth,  ....  596 

Hunter,  Dr.  John,  researches  on 

the  development  of  teeth,     99 
Hunter's,  Dr.  Wm.  M.,  continuous 

gum  recipes,       .  .  755 

Hydrostatic  blow-pipes,        .         .     678 
Hyoid  muscles,         .         .         .  77 

Digastricus,  .         .         .         .77 
Geniohyoideus,        .         .  77 

Genio-hyo-glossus,        .         .        76 
Hj'o-glossus,     ...  76 

Mylo-hyoideus,      .         .         .77 

I. 

Impressions  in  wax  and  gutta-percha, 645 

Cups  and  materials  for,     .    -  <i43 

Austen's  gutta-percha  cup,  649 

Cleaveland's  cups,          .  644 

Franklin's  cup,  .         .  644 

In  plaster  of  paris,    .         .  648 

Desirabodc's  method  of,         -  'JSl 

Inclined  plane  of  Catalan,        .  156 

Incorruptible  teeth,       .         .         •  599 

India-rubber,  history  of,  .         .  761 

Ligatures  for  regulating,        .  154 

For  separating  teeth,     .  280 

Vulcanized,.         .        160,761,851 


PAOB 

35-37 
35 
36 
35 

37 


Inferior  maxillary  bone,   . 
Its  divisions. 

Alveolar  processes. 
Anterior  mental  foramina 
Articulation, 
Condyloid  processes,  .       37 

Coronoid  processes,       .  37 

Development,     .         .         .37 
Genial  processes,  .         .  36 

Posterior  dental  foramina,        37 
Rami,    .         .         .         .  37 

Structure,  .         .         .37 

Inflammation  of  dental  pulp,  .  424 

Of  the  gums,         .         .         .     457 
Mercurial,      .         .         .  469 

Of  the  maxillary  sinus,  .     508 

Ingot  moulds,  .         .         .  637 

Insalivation,  organs  of,         .  67-69 

Arteries  of  these  organs,  .  84 

Insertion  of  artificial  teeth,  differ- 
ent methods  of,  .  601 
Intemperance,  effect  on  gums,      .     208 
Introducing  and  consolidating  crys- 
talline gold,  .         .         .     335 
Irregularity  of  the  teeth,  .          144,  146 
Age  for  correcting,       148,  149.  159 
Cases  of,  .         .         .            152-158 
Catalan's  inclined  plane,        .     156 
Caused  by  want  of  room,  1 49 
Contraction  of  upper  jaw,        145 
Defect  in  conformation,           145 
Connection  with  second  den- 
tition,   .         .         .       138-143 
Correction  by  vulcanite,      160,  162 
Directions  of  Fox  in,     .         .     148 
File  never  to  be  used  in,   .          141 
Fox's  plan  of  correcting,       .     158 
Importance  of  early  attention  to,  148 
Ligatures  in  correcting,       151,  154 
Of  bicuspids,    .         .         .          146 
Of  cuspids,  .         .         .         .147 
Of  dens  sapientiic,    .         .          144 
Of  incisors,  .         .         .       150-154 
Of  molars,         .         .         .          144 
Predisposing  cause  of  disease,   142 
Teeth  most  liable  to,           144,  145 
Treatment  of,         .         .      146-162 
General  principles  of  treat- 
ment,    .         .         .      147,  162 
Where  under  teeth  jjroject,     155 
Itinera  deutium,       .         .         .          lo6 
Ivory  for  artificial  teeth,       .         .     598 


Jaw.  luxation  of  lower,    .         .  16 

E.xcessive  development  of,     .      1  *'>3 

Treatment,    .         .         .  164 

Protrusion  of  lower,     .         .106 

Treatment,  .  167 

Superior,  excision  of,    .      570-573 


864 


INDEX. 


Jaws,  accretion  of  the,     . 
Chanpes  produced  by, 
Commencement  of,    . 
Defects  of,     . 

Hereditary  nature  of. 
Necessity  for. 


K. 

Kaolin,    .... 
Key  of  Garengeot, 

Manner  of  using. 
Koccker  on  second  dentition. 


PAOR 

I.'^S-IST 
.      1.35 

135 
.      136 

137 
.     135 


731 
35» 
361 
142 


Lavater  on  temperaments.  100-193 

Lead  over  exposed  nerves,    .  .312 

For  metallic  dies,      .  .          660 

Lips,  characteristics  of  the.  .     223 

Symptomatic  of  health,  .          224 

Lithodeon,  (amalgam,)          .  .     270 

Lower  jaw,  dislocation  of,  .          439 

Reduction  of,         .         .  .     441 

Sir  Astley  Coopers  method,      442 


M. 


Maconiber's  blow-pipe, 
Malar  process. 
Mastication — active  organs, 
Their  arteries,  . 
Inferior  dental, 
Infra-orbital, 
Internal  ma.xillary,     . 
Spheno-palaline,   . 
Superior  i>alatiDe, 
Superior  dental,     . 
Temporal, 
Their  muscles, 
Masseter,  . 

Pterygoideus  externus, 
Pterygoideus  internus. 
Temporalis,  . 
Mastication — passive  organs, 
Inferior  maxilhe,  . 
Palate  bones.     . 
Superior  maxilla\ 
Teeth. 
Materials  n.<ed  for  block  teeth. 
Matrix  for  moulding  block  teeth. 
Of  sand  for  metallic  dies,  . 
For  vulcanite, 
Maxillary  bones,  superior. 

Bone,  inferior. 
Maxillary  sinus,  anatomy  of. 

Diseases  of,       .         .  4<)9 


679 

33 

64-66 

83-86 

83 

83 

83 

84 

84 

83 

84 

64-66 

65 

65 

66 

64 

31-61. 

35-37 

38,39 

31-34 

39-63 

730 

742 

658 

771 

33,  31 

35-37 


PAOB 

Maxillarj'  sinus. 

Abscess  of,    .         .         .      504-533 

Causes  of,      .         .         .         536 

Symptoms  of,     .         .         .     535 

Treatment  of,         .         .  537 

Caries  and  necrosis  of,        505,  550 

Causes,  .         .         .  552 

Symptoms  of,     .         .         ,551 

Treatment  of,         .         .  553 

Causes  of  diseases  of,   .         .     505 

Exostosis  of  the  bony  walls  of,    574 

Symptoms  and  causes  of.  .     577 

Treatment  of,  .  .  578 

Foreign  bodies  in,  .         .     587 

Inflammation  of,        .  504, 508 

Causes  of,  .         .         .510 

Symptoms  of,         .         .  5<.i> 

Treatment  of,     .         .         .511 

Insidious  nature  of  disease  in,     503 

Mucous  engorgement  of,     504,  512 

Penetrated  by  teeth,  .  507 

Preliminary  remarks  upon,  501-507 

Purulent  secretions  of,  504,  512-532 

Cases  of,    .         .         .      523-532 

Causes  of.      .         .         .  517 

Symptoms  of.    .         .         .516 

Treatment  of,         .         ,  518 

Tumors  of  lining  membrane 

and  periosteum  of  the,  5,")7-573^ 

Cases  of,   .         .         .      564-570 

Causes  and  treatment  of,        561 

Symptoms  of,    .         .         .     560 

Ulceration  of  membrane  of,       542 

Causes  of,  ...     544 

Symptoms  of,         .  .  543 

Treatment  of,     .         .         .     545 

When  discovered,      .         .  501 

Wounds  of  the  walls  of,         .     583 

Treatment  of,         .         .  584 

Maynard's  forceps,        .         .         .377 

File,  ....  3()£> 

Drill  stock,    ....     274 

Theorj-  of  sensitive  dentine,         50 

Mechanical  abrasion  of  teeth,       .     411 

Exposure  of  pulp,  how  prevented,412 

Violence,  injuries  from,       .  413 

Mechanical  dentistry,  .         .         .    .591 

Meckel  s  ganglion,    .         .         .  8!> 

Mental  process,    ....       35 

.Mercurial  intiammation  of  gums,     461' 

Metallic  dies  and  couuier-dies,     .     656 

Dipping  process,        .  .  657 

Dr.  Clark's  method,       .         .     656 

Dr.  Gunning's  method,      .  657 

Fusible  metal  process,  .         .     656 

Sand  moulding,         .         .  658 

Mineral  cement  (amalgam),  .     270 

Models  of  the  mouth,  plaster,  .  651 

Mother,  health  of,  indicated  by  teeth 

of  child,    .         .         .  188 

Moulding  and  carving  block  teeth.     744 

Flasks,      ....  659 


INDEX. 


865 


PAIIE 

Sloutli,  acids  in  the,  .  .  .  249 
Its  Mnrttomy  and  physiology,  27-1  Hi 
Anatomic-ill  relations  of,    .  95 

Arteries  of,  .  .  .  .88 
Blood-vessels  of\  .  .  81-86 
Elements  of,  ...       27 

Fluids  of  the,  characteristics  of,  220 
Mucous  membrane  of,  .  .  77 
Muscles  of  the,  .  29,  30,  64-77 

Nerves  of,      .  .  .  87-95 

Physiological  relations  of,  9G 

Preparation  of,  for  insertion 

of  artificial  teeth.       .  609 

Veins  of,  .  .  .  .8(5 
Wash,  author's  recipe  for,  464 

Mucous  ghinds,     ....       69 

Membrane  of  the  mouth,  .     77,  78' 

Of  the  alveolar  processes,  .       79 

Of  the  tongue,        ^         .  75 

Muscles  of  the  mouth,  .  28-30 

Buccinator,       .         .         .  .SO 

Depressor  labii  inferioris,  .  29 
Dej)ressor  labii  superioris,  30 

Depressor  anguli  oris.  .  .  29 
Levator  labii  superioris  ala?que 

nasi,  ....  29 

Levator  anguli  oris,  .  .  29 
Levator  labii  inferioris,     .  30 

Oibicularis  oris,  ...  30 
Zygomaticus  major,  .         .  29 

Zygomaticus  minor,       .         .       29 


.Nerves  of  <<rie  .Mouth, 

Meckel's  ganglion, 

89 

Nasal, 

90 

Orbital, 

90 

Palatine,    . 

89 

Posterior  dental,    . 

91 

Pterygoid, 

90 

Vidian.  .... 

90 

(c)  Inferior-maxillary  branch, 

91 

Anterior  auricular, 

92 

Buccal. 

92 

E.xternal  branch,    . 

92 

Gustatory, 

92 

Inferior  dental. 

93 

Internal  branch, 

92 

Masseteric, 

92 

Mylohyoid, 

93 

Pterjgoid, 

92 

Temporal. 

92 

S^erve  of  tooth,  modes  of  destroying 

322 

Author's  method,  . 

327 

Dunning's  method,    . 

324 

Foster's  method,   . 

325 

Harwood's  method.  . 

323 

Maynard's  method,        .      325 

326 

Gutta  percha,  in  exposed, 

315 

Filling  over  expo.sed,     . 

310 

Author's  method,  . 

316 

Hullihen's  method,    . 

316 

Nitrate  of  silver  lotion,    . 

465 

0. 


N. 

Nasmyth's  membrane, 

Microscopical  researches. 
Views  on  dentine,     . 
Nasal  crest. 

Spine.        .         .         .  . 

Necrosis  of  alveoli. 

Causes  and  treatment  of,  . 
Nerves  of  the  mouth,    . 

Facial  (portio  dtint  of  7th  pa 
Cervi co-facial  division, 
Buccal,       . 
Cervical, 

Infcrior-ma.Nillary, 
Stylo- mastoid  division, 
Posterior  auricular,    . 
Digastric, 
Stylo-hyoid, 
Tem|)oro-facial  division, 
Trigeminus  (.")th  pair), 
Casserian  ganglion,    . 
((()  Ophihalmic  branch. 
Frontal. 
Lachrymal, 
Nasal,"    . 
(i)  Superior  maxillary  ijran 
Chorda  tympani, 
Infra-orbital, 


52,  115 
42 

110 

33 

33 

.   489 

492 
87-95 
irj  93-95 
95 
95 
95 
95 
94 
94 
94 
94 
94 
87-93 
88 
88 
88 
88 
89 
89 
90 
91 


ch, 


Obturators  or  artificial  palates. 

832 

First  descrijjtion  of,  . 

832 

Manner  of  constructing. 

834 

Desirabode's,     . 

857 

.Mr.  Howell's, 

855 

Simple,     .         .         •         . 

835 

With  drum,  . 

834 

Oral  teeth 

58 

Opercula  of  dental  follicles, 

103 

Osteo-dentine, 

311 

Osleo-plastic, 

272 

Osteo  sarcomatous  tumors, 

480 

Osseous  union  of  teeth, 

172 

Owen,  Professor,  views  oa  forma- 

tion of  dentine, 

108 

109 

Oxide  of  cobalt. 

735 

Of  gold,  mode  of  preparing, 

733 

Of  nuinganese, 

735 

.      Of  silver,       . 

735 

Of  titanium. 

735 

Of  uranium. 

735 

Oxy-chloride  of  zinc. 

271 

Palate,  hard. 

Diseases  of  the. 


33 

801 


866 


INDEX. 


Palate. 

Caries  and  oecrosis  of,  .         .     806 

Causes  and  treatment  of,        808 

Palate,  soft,  ....       72 

Muscles  of  the,  .         .      73,  74 

Azypos  uvulif,  ...       74 

Con.-trictor  isthmi-fiiuciuin,      73 

Levator  paliiti.  .         .  .73 

I'iilato-pliaryngeus,        .  73 

Tensor  ])alati,    ...       73 

Tumors  of  the,  .  801 

Causes  of,  ...     802 

Treatment  of.  804 

Palate  bones.       ...  38.  39 

Anatomy.  ...  38 

Development,        ...       39 

Nasal  plate,       ...  38 

Orbital  process,     ...       38 

Relations,  ...  38 

Structure,     ....       39 

Imperfections  of  the,         .  813 

Palate  plate,  simi)le  artificial,        .     835 

With  drum  on  convex  surface,  834 

With  velum  and  uvula.  .     836 

Dr.  HuUihen's  invention,  .  840 

Dr.  Blandy's  modification,     .     842 

Dr.  Kingsley's  invention,  .  843 

Mr.  Stearns'  invention,  .     837 

With  artificial  teeth,  .  853 

Palatine  obturator  of  M.  Desirabode,  857 

Palatine  organs,  defects  of,       .  815 

Accidental,   .         .         .         .815 

Congenital,       .         .         .  816 

Diseases  of.  .         .         .         .     799 

Functional  disturbances  from,    818 

Manner  of  remedying,  .         ,     822 

Papilla^  of  the  tongue,  .  75 

Conical,         ....       75 

Filiform,  ....  75 

Fungiform,    ....       75 

Lenticular,        ...  75 

Dental,  .         .         .        98-102 

Parotid  glands — anatomy,         .  67 

Function  of.  .         .         .68 

Parotidean  ple.xus,    ...  94 

Parmlys  self-acting  blow-pipe,     .     673 

Peculiarities  in  gr.j\vth  of  teeth,     168 

Peening  or  paning  band  to  plate,     750 

Periosteum,  alveolo-dental,       .  79 

Inflammation  of,   .  437 

Pes  anserinus,  .  1(4 

Pharynx — anatomy,  .  .70 

Arteries  of,        .         .         .  84 

Muscles  of,    .         .  71-72 

Physical  characteristics,  .         .  183 

Of  the  buccal  fluids,     .         .     220 

Of  the  gums.    .         .  205-214 

Of  the  lips,   ....     223 

Of  salivary  calculus.  215-219 

Of  the  teeth,  .  196-204 

Of  the  tongue,  .  226-230 

Physiognomy,  importance  of,        .     191 


VAOE 

Pickling  after  soldering,  .         .  695 

Pivot  teeth,  insertion  of,       .      601,612 

Plaster  of  paris.  composition  of,       648 

Articulators,  .  .       683,  741 

Models,  manner  of  making,        651 

Plates,  gold,  preparation  of.  .     6.S7 

Finishing  up,     .  .  .  695 

Soldering  teeth  to,         .         .     692 

Swaging,  .  .         .  .  661 

Platina  sponge,  how  prepared,      .     733 

Porcelain  teeth,        .  .  .  599 

Advantages  of,      .         .         .     600 

Different  methods  of  inserting,    601 

Objections,  to,       .         .         .     600 

With  gums,  single  or  in  sections, 702 

With  continuous  gums,  .     753 

Block  teeth,      .         .         .  7:i0 

Crucing  or  biscuiting,         .      74(5 

Enameling  of,         .  .  747 

Firing  and  baking,     .  .     747 

Fitting  and  attaching  to  plate, 749 

Materials  for,     .         .         .     730 

Moulding  and  carving,  744 

Platina  pins  of,  .  .      746 

Superiority  of,       .         .  730 

Porte-aiguille,      "...     826 

Posterior  nasal  spine,       .         .  38 

Posterior  palatine  canal,       .        '.        38 

Posterior  palatine  foramen,      .  38 

Preformative  membrane,      42,  108.  115 

Prehension,  organs  of,      .  .      28-30 

Prevention  of  caries,    .         .     4  •     251 

Primitive  dental  groove,  .         .  102 

Professor  Austen's  impression  cups,  649 

Artificial  molar  crown,      <  343 

Alloy  rules  and  formulae,        .     635 

-Moulding  with  false  cores,  654 

-Method  of  fitting  clasps,        .     669 

Rules  for  soldering.  .         .  670 

Hydrostatic  blow-pipe,  .     678 

Manner  of  arranging  teeth  for 

soldering,  .  .  .  692 
Theory  of  the  vacuum  cavitj',  7 1 7 
Use  of  the  vacuum  cavit}',  .  729 
Chapter  on  vulcanite,        .  761 

Prof  Ch.  Johnston's  discovery  of  sen- 
sitive fibres,  or  enamel  cells,  50 
Prof.  Joseph  Richardson's  method 

of  pivoting,  .  .  .      778 

Treatise  on  mechanical  dentistry, 595 

Protrusion  of  lower  jaw,       .  .166 

Pulp,  dental — anatomy,    .  .      41,  44 

•"Cellular  structure  of,      .  .       43 

Converted  into  osteo-dentine,     31 1 

Foster's  expectant  treatment  of,  315 

Fungous  growth  of,  .  435 

-Microscopical  appearance  of,       43 

Nerves  of,  ...  44 

Ossification  of,       .  .  .     436 

Spontaneous  disorganization 

of,      .         .         .  433 

Blood-vessels  of,  .         .         .       43 


INDEX. 


861 


Pulp-cavity,  treatment  when  nearly 

exposed,         .         .         .     285 

Prof.  Gorgas'  preparation  of,     328 

Punch  for  extracting  roots,  .     37  + 

.Forceps,    ....  690 

Dr.  Mallet's,       .         .         .691 


R. 

Ramus  of  lower  jaw, 
Raschkow,  researches  of, 
Red  gum, 
Refining  gold. 

Dr.  Elliot's  method,  . 
Remedies  for  tooth  ache. 
Rickets,  effects  on  dentition, 
Rolling  mills, 
Roots  of  teeth,  extraction  of, 

Destroying  nerve  in. 

Exostosis  of, 

Gradual  wasting  of, 

Manner  of  filling. 

Preparation  of,  for  pivot, 
Rouge,  jewelers,  how  made, 


lis. 


o  ( 

114 
122 
625 
631 
351 
136 
638 
373 
322 
398 
237 
318 
612 
696 


Saliva,  physical  characteristics  of,     220 


Salivary  glands,        .         .         .      67-69 

Parotid,         .... 

67 

Sublingual, 

69 

Submaxillary, 

68 

Calculus  (see  tartar), 

445 

Characteristics  of, 

215 

Classification  of,    .           216 

,217 

Foliation  of,     .         ... 

447 

Effects  of,  upon  the  teeth, 

451 

Manner  of  removing, 

453 

Morbid  eff"ects  of,  . 

218 

Screw,  conical,     .... 

374 

Screw-forceps,  Hullihen's, 

376 

Schwerdt's  needle-holder,    . 

826 

Scorbutic  persons,  gums  of. 

212 

Scrofulous  persons,  gums  of. 

212 

Scurvy,    

455 

Second  dentition, 

130 

Direction  of,      .         .         .      ■ 

138 

Secondary  dental  groove,     . 

104 

Splf- acting  blow-pipes,     . 

673 

Elliot's  improvement  of, 

675 

Dr.  White's  improvement, 

674 

Sensibility  of  the  teeth,  how  to  de- 

stroy. 

266 

Dr.  Maynard's  theory  of. 

50 

Septic  acid  formed  in  the  mouth, 

248 

Separation  of  the  teeth  by  the  file, 

259 

By  pressure. 

280 

Siuims,  Dr.  .Marion,      .         .      816, 

830 

PAUE 

72-76 

85 

641 

642 

670,  692 


Soft  palate,  the, 

Arteries  of,   . 
Solder,  manner  of  making 
Recipes  for,  . 
Directions  for  using. 
Soldering,  principles    and   appli- 
ances of,    .         .         .  670 
Lamps,           .         .         .         .671 
Pan,          ....          680 
Somerby's  furnace  and  blow-pipe,     677 
Spheno-palatine  ganglion,        .  89 
Spheno-palatine  foramen,     .  38 
Spina  ventosa,           .          .          .          402 
Causes  and  treatment  of,       .     403 
Spiral  springs,  manner  of  making,     641 
Application  of,      .          .          .     699 
Attachments  for,        .         .          701 
Spong3'  growth  of  the  gums,        .     212 
Spontaneous  ulceration  of  the  gums,  471 
Springing  of  plates,               .       692,  722 
Staphyloplasty,         .          .          .           831 
Staphyloraphv,    .         .         .       823-830 
History  of,         .         .         .          823 
Instruments  necessary  for,     .     823 
Mr.  Fergussou's  method,  .          828 
Dr.  Hullihen's  method,           .     826 
M.  Roux's  method,    .         .          825 
Dr.  N.  R.  Smith's  method,          827 
Dr.  Warren's  method,        .          827 
Insertion  of  ligatures,  .         .     825 
Dr.  Marion  Simiiis'  ligatureS^     83(J 
Steno,  duct  of,      ....       68 
Strumous  diathesis,  gums  in,  .          210 
Stub's  files,           .         .         .         .     262 
Submaxillary  glands,        .         .            68 
Sublingual  glands,        .         ,         .69 
Substances  used  for  dental  substi- 
tutes,    ....     596 
Substitutes,  dental,  for  special  cases,  709 

712 
713 
709 
Till 
71! 

714 

716 

71(1 

174 

31-34 

32 

3  J 

:-!4 
34 

57(1 

3:; 
;!4 

825 

830 

661 

35 

95 


Bicuspids,  with  clasps. 

Roper's  plan, 
For  incisor  with  one  clasp, 
With  two  clasps,  . 
Incisors  and  cuspids. 
Incisors,  cuspids   and   bi- 
cuspids, 
Incisors  and  bicuspids. 
Two  central  incisors, 
Supernumerary  teeth, 
Superior  ma.xilla,  anatomy  of. 
Alveolar  processes  of. 
Anterior  dental  canal  of, 
Articulation  of, 
Development  of,    . 
Extirpation  of,  . 
Infra-orbital  canal. 
Structure  of, 
Sutures,  in  etaphyloraphy,   . 

Dr.  Simms'  metallic, 
Swaging  plates,   . 
Symphysis  of  lower  jaw, 
Sympatheticus  minor. 


81)8 


INDEX. 


Tartrtr  (salivary  calnilus),  215,  445 

Chemical  coiis'.itiients  of.       .     446 

Coloi- of,  difterences  in,     .  216 

Dark  brown.     .         .         .  217 

Dark  green.  .         .219 

Densitv  of,  variable.  .  216 

Dry  black,    .  .         .      215.216 

Second  variety,      .  .  216 

Dry  yellow  or  light  brown,   .     215 

Effects  in  scorbutic  subjects,  205 

Its  diagnostic  import,         .     215 

Effects  of,  upon  teeth,  gums,  &c.,451 

Manner  of  removing.         .  453 

Origin  and  deposition  of,  447 

Pale  or  vcliow  brown.        .  217 

Effects  of,  .         .         .218 

Universal  liability  to  it,     .  215 

White,  .         .  .218 

Teeth,  anatomy  of,  .  .      39-61 

Abrasion  of.  spontaneous,  408 

Mechanical,        .  .  .411 

Anatomical  divisions  of.    .  39 

Articulation  of,     .  .  61,  62 

Artificial,    (see  Artificial.)  592 

Atrophy  of,  .  .  .387 

15icusi)id,  an.'itomy  of,        .  58 

Buccal,  (bicuspids  and  molars.)     CI 

Caries  of.       ....     234 

Cementum  of,  .         .         .    54-116 

Characteristics  of,  .         .196 

Classification,  (anatomical.)  56-61 

Constitutional,  .         .       196-204 

First  class,  .  .  196 

Where  found,     .         .     196 

Opinion  of  Lavater,  197 

Second  class,  .         .198 

Show  a  weak  constitution  1 99 

Where  mostly  found, .      199 

Third  class,        .  .  199 

Fourth  class,  .      201 

Fifth  das.';.         .  .  201 

Component  structures  of,      .       .^9 

Crowded,  how  to  correct,  140 

Cuspid,  anatomy  of,      .  .       57 

Deformity  from  excessive  de- 

velo])menl  of  lower.         .      163 
Dentine,  .     45-51,108-112 

Density  of,  increased  by  age,  184 
Denuding  of,  .        \  404 

Causes  of,       .  .     405 

Treatment  of,     .  .  407 

Development  of,  ]01-108 

Differences  in  liability  of  dif- 
ferent, to  decay      .         .     237 
Differences    between    tempo- 
rary and  permanent.      .     130 
Diseases  of  the,         .         .  2.33 

Displacement  of,  .         .         .     49G 
Causes  and  treatment  of.       496 
Enamelof,         .        51-54,  1 1.3-1  !•> 


Teeth— 

Exostosis  of  roots  of,     .         .     398 

Cases  of,        .         .         .  399 

Causes  and  treatment  of,  .  400 
Extraction  of,  .         .  355 

Indications  for,  .  .     357 

Instruments  employed  in,  359 
Eve,  (upper  cuspids,)  .       58 

Filing  of,  ...  254 

Dr.  J.  Harris  on,        .       254, 259 

Method  of,     .         •         .  259 

Filling,  ....      264 

Pulp-cavity  and  root,    .  318 

Filling  over  exposed  pulp,  .  310 
Fractures  of,     .  .  .  413 

General  considerations,  184-195 
Importance  of  attention  to,  251 
Incisor,  anatomy  of,       .  .        56 

Increase  ot  density  in  the,  198 
Influence  of  animal  food  on,  247 
Injury  from  neglect  of,      .  138 

Irregularity  of  the,  .      144-162 

Materials  used  in  filling,  .  266 

Membranes  of,  vascular,  .  43 
Molar,  anatomy  of,    .         .  60 

Necrosis  of,  ...     396 

Causes  and  treatment  of,  397 
Oral,  (incisors  and  cuspids,)  58 
Order  of  eruption  of,  .  119,132 
Origin  and  formation  of,       98-118 

Described  by  early  anatomists,  99 
John  Hunter,  .  .      100 

Dr.  Blake  and  Mr.  Bell,       100 
Arnold  and  Goodsir,   101-108 
Commencement   of  ossifica- 
tion of,  .         .         .111 
Osseous  union  of,      .         .  172 
Peculiarities      in     formation 

and  growth  of,        .     168-171 
Permanent,  number  of,  41 

Pulp  of,  .  .  .      41-44 

Eruption  of,  ...      1.30 

Order  of  eruption.         .  132 

Physical  characteristics  of,  .  196 
Pivot,  insertion  of,  .     601,612 

Position  of.  at  fifth  year,       .     131 

At  fourteenth  } ear,       .  132 

Predisi)Osition  to  decaj',  238-241 
Porcelain,  (see  Porcelain.)  599 

Protrusion  of  lower  front,     .      163 
Ajijiaratus  for  correcting,        164 
Relations  of  upper  to  lower,         62 
Singular  growth  of  teeth,  168 

Abrasion  of  cutting  edges  of,     408 

Causes  and  treatment  of,  409,  410 
Stomach,  (lower  cuspids,)  58 

Suitable  for  clasping,         .  705 

Suitable  for  pivoting,    .  .      60 1 

Supernumerary,        .         .  174 

Susceptibility  of,  to  decay,  .  184 
Temporary,  classification  of.         40 

Number  of         .         .         .       40 


INDEX. 


809 


PAGE 


Teelli, 

Eruption  of. 
When  to  be  extracted, 
Transposition  of  germs  of. 
Wisdom  or  denies  sapientiae, 
Teething,  active  stages  of, 

Effects  and  symptoms  of,    122,  124 
Temperaments    according  to    La 


117 

145 

t)l 

122 


vater 
Temporary  teeth, 
Ernption  of, 
Extraction  of,   . 
Periods  of  eruption  of, 

Theory  of. 
Shedding  of,     . 

Singular  notions  about, 
.  Theory  of  Fox, 


190,  193 

117 

.     117 

378 

119 

.      118 

125,129 

.      125 

125 


Theory  of  Lafi.rgue,  .      126 

Theory  of  Delabarre,  120 

Theory  of  the  author,  .     128 

Third  dentition,          •          •  176-182 

Tonic  month  wash,  Harris',  •     464 

Tongue,  anatomy  of,          •  '76,  77 

Arteries  of,  .         •         •  •       "-^^ 

Characteristics  of,     .  •          220 

Coatings  on,          •         •  •     -;"' 

Diminution  of,            •  •          ^27 

Enlargement  of,    .         •  .     2Li 

Indicative  of  state  of  health,     226 

Muscles  of,         .         •  •     75,7.7 

Genio-hyo-glossus,    .  "( 

Hyo-glossus,          .  •            7(. 

Lingualis,          •         •  .       7  ( 

Stylo-glossus,        .  •            7f 

Moist,  diagnosis  of,        •  •     221 

I'apilUe  of,         •         •  •            ^| 

Pustules  on,            •          •  •     22! 

Senieiology  of,           •  .  •          -^^ 

£■  9')' 

Secretions  01,          .          •  .     ^- 

Tonsil  glands ^ 

Tuoth-iiche,           •         •         '  "     "     ol 

Idiopathic,         .         .  ■         ■^•* 

Causes  of,     -         •         •  '     'f'^ 

Neuralgic,         .         "  •          ;'"' 

Treatmen;  of,         •          •  •     •*[' 

Tooth  powder,  recipes  for,  .          2:) 

i'ownst-nds  files,  '         '         '     Tt 

Transpositions  of  the  teeth,      ,  14 

Trigemini.  (5th  pair  of  nerves,)      87-£ 


Upper  jaw,  (see  superior  maxilla. 
Uvula,  the. 

Ulceration  of,    , 

Elongation  of. 

Scissors,  lluUilft'n's, 

Artificial, 


Vacuum  cavity, 
Theory  of,     . 
Utility  of,  .         ■         • 

Various  forms  of. 
Varnish  for  models. 
Veins  of  the  mouth, 
Velosynthesis, 
Vidian  nerve. 
Velum,  artificiiil, 

Intlainmation  of,   . 
Vesico- vaginal  fistula,     . 
Vulcanite,  history  of. 
Advantages  of. 
Antagonizing  plates  for. 
Antagonizing  models  for, 
Coinposilion  of,     . 
Disadvantages  of, 
Durability  of, 
Elfecl  of  vermiUiDU  in. 
For  correcting  irregularity 
For  pivot  teeth, 
For  artificial  palate. 
Finishing  up,    . 
Iin[)ression  for. 
Models  for. 
Packing  in  Hasks, 
Repairing, 
Teeth  suitable  for, 
Time  of  heating. 
Vacuum  cavity  in, 
Vuhanizing  heaters, 
Of  copper,     . 
Of  iron, 
Lamps, 
Process,    • 


PAOK 

31 

74 

Mil 

811 

-136 


724 
.      7IS 
720 
.      726 
655 
86 
823 
90 
836 
.      811 
830 
.      761 
781 
.      76.") 
765 
.      762 
780 
.      779 
763 
,   .      160 
778 
837, 851 
774 
.      764 
765 
.     771 
775 
.     767 
773 
775 
76« 
.     768 
767 
.     769 
772 


W. 


U. 

Ulceration  of  mucous   membrane 
Of  the  palate,    . 
Of  maxillary  sinus, 
Of  the  gums,     . 
Of  the  velum  and  uvula. 


Wasting  of  alveolar  processes  .     4J3 

Wax  impressions  of  the  mouth,  t>4.. 
Weslcott's  experiments  on  the  teeth,  249 

I  Wharton,  duct  of,     .          •          •  /||| 

Wire  draw-plate,           •          •  •     y  [^ 

Wood  suitable  for  pivots,          .  ^'^ 

!  Wood's,  Dr.  B.,  fusible  metal,  .     -/O 


LINDSAY  &  BLAKISTON'S  PUBLICATIONS. 


TOMES' 
NEW  SYSTEM  OF  DENTAL  SURGERY. 

This  book  has  the  advantage  of  being  all  that  could  be  desired  in  a  Manual  of  the  Art,  ahlv 
filling  a  void  long  felt  in  general  surgical  literature,  and  vcell  calculated  to  uphold  dental 
surgery  in  the  high  position  to  which  it  has  attained  as  a  scientific  branch  of  the  healing  art. 
To  the  library  of  country  practitioners  especially,  it  will  be  an  invaluable  addition.  Liable  ss 
they  are,  to  be  more  frequently  appealed  to  in  cases  of  dental  pathology  than  their  brethren 
in  the  large  cities  where  specialists  abound,  they  will  do  well  to  fortify  themselves  by  acquir- 
ing the  extended  acquaintance  with  the  subject  this  work  will  afford. — Dublin  Medical  Quar- 
terly. 

A  System  of  Dental  Surgery^ 

By  John  Tomes,  F.R.S.,  Dentist  to  the  Dental  Hospital  of  London, 
author  of  "  Tomes'  Dental  Physiology,"  &c.  &c.  With  208  beauti- 
fully executed  Illustrations.     In  One  Volume,  Octavo.     Price,  $3.50. 


OPINIONS  OF  THE  PRESS. 
We  now  come  to  the  most  important  and  interesting  work  connected  with  the  subject  of 
dental  surgery.  The  name  of  the  writer  would,  from  his  antecedents  alone,  be  sufficient  to 
raise  great  expectations  of  any  coming  work  from  his  pen,  and  such  expectations  will  not  b« 
disappointed  by  a  perusal  of  it.  His  labors  and  previous  writings  on  the  subjects  which  he 
has  so  vigorously  and  successfully  prosecuted  justly  entitles  him  to  the  highest  rank  as  a 
physiologist,  and  bis  last  publication  adds  another  to  his  already  well  deserved  honors.  The 
whole  work  has  been  carefully  got  up,  and  it  is  impossible  to  speak  too  highly  of  the  admira- 
ble manner  in  which  the  illustrations  have  been  executed. — British  and  Foreii/n  Med.  Chirug. 
Review 

Tue  need  of  a  truly  scientific  treatise  upon  the  physiology  and  pathology  of  the  teeth  has 
long  been  felt  in  this  country,  especially  by  practitioners  in  the  rural  districts,  who  have  to 
act  the  part  of  dentist  as  well  as  physician.  The  work  of  Mr.  Tomes  admirably  supplies  this 
want.  It  is  the  production  of  a  master  mind,  after  years  of  patient  labor  in  an  ample  field  for 
observation  and  careful  investigation. — N.  Y.  Journal  of  Medicine. 

The  distinguished  author  has  supplied  us  with  a  model  of  composition  at  once  pure, 
chaste,  and  classical ;  and,  in  taking  leave  of  him,  we  beg  to  declare  that  his  work  is  one  of 
the  most  readable  scientific  books  in  the  English  language. — N.  Am.  Medico- Chirurgica I 
Review. 

The  scientific  reputation  of  the  author,  the  practical  character  of  the  work,  and  the  two 
hundred  and  eight  engravings,  executed  in  Mr.  Bagg's  best  style,  must  constitute  it  the  book 
of  reference  to  all  practicing  the  art  of  dentistry. — The  Lancet. 

We  feel  no  hesitation  in  recommending  this  as  an  ably  written  and  valuable  work,  con- 
taining much  original  matter  that  cannot  be  found  elsewhere,  and  calculated  to  enhance  tlie 
reputation  the  author  has  already  established,  of  being  an  original,  pains-taking  and  careful 
observer.  We  trust  that  it  will  meet  with  a  large  and  extended  circulation  among  the  pro- 
fession here  and  elsewhere.  The  letter  press,  illustratious,  and  binding,  are  excellent  and 
reflect  much  credit  upon  the  publishers. — Dental  Cosmoi. 


LIND-AV  k  BLAKISTONS  PUBLICATION'S. 


Taffs  Practical  Treatise  on  Operative  Dentistry, 

By  Jonathan  Taft,  D.D.S.,  Professor  of  Operative  Dentistry  in  the 
Oliio  College  of  Dental  Surgery,  &c.  With  eighty  well-executed  lllus- 
tnitions.     In  One  Volume.     Price,  $3.00. 

An  examination  of  M:-.  Tafi's  treiUise  enables  us  to  speak  most  favorably  of  it.  It  is  very 
thorouirli  ;»n<l  verv  clear,  .showing  that  the  author  is  i)ractically  f.uuiliar  with  the  arc  which 
he  teaches.  Tlie  engravings  are  abundant  and  e.\cellent,  and,  in  fact,  the  whole  mechanical 
execution  of  the  volume  is  admirable,  and  reflects  much  credit  on  the  publishers. — Boston 
Med.  and  Surff.  Journal. 

Dr.  Tafi  evinces  an  intimate  and  practical  knowledge  of  what  he  is  writing  about,  and  in 
all  cases  uses  such  simple  and  well-chosen  language  that  there  is  no  mistaking  the  idea  he 
wishes  to  convey.  This  is  one  of  the  most  valuable  books  ever  published  for  the  use  of 
ftudents  of  Dental  Surgery. — Chicago  Med.  Journal. 

The  book  speaks  for  itself.  It  is  most  read.able  in  its  style,  carefully  and  laboriously  com- 
piled, well  illustrated,  and  containing  much  valuable  information.  Wo.  thcrcibre.  hail  it  as 
another  valuable  addition  to  our  stock  of  information  on  the  subject. — KiUnhnrjh  Med.  Jd'nii'il 

Richardson^ s  Practical  Treatise  on  Mechanical 
Dentistry, 

By  Joseph  PticiiARDSON,  D.D.S.,  Professor  of  Mechanical  Dentistry 
in  the  Ohio  College  of  Dental  Surgery,  &c.  In  One  Volume,  Octavo, 
with  over  100  beautifully-executed  Illustrations.  Just  Ready.  Price, 
P.50. 

Ilanch/s  Te:d-Booh  of  Anatomy^ 

And  Guide  to  Dissections.  For  the  use  of  Students  of  Medicine  ana 
Dental  Surgery.  By  Washington  R.  Handy,  M.D.,  late  Professor 
of  Anatomy  and  Physiology  in  the  Baltimore  College  of  Dental  Sur- 
gery.    With  312  Illustrations.     One  Volume.     Price,  $3.00. 

We  heartily  commend  it  to  both  the  medical  and  dental  profession,  as  a  thorough,  faithful, 
md  physiolopical  treatise  on  anatomy. — American  Journal  of  Dental  l^cieuce. 

Bond's  Practical  Treatise  on  Dental  Medicine; 

Being  a  Compendium  of  Medical  Science,  as  connect' d  Avith  the  study 
of  Dental  Surgery.    By  Thomas  E.  Bond,  M.D.,  ProR'ssur  (f  Special 
Pathology  and  Therapeutics  in  the  Baltimore  College  of  Dental  Sur- 
gery.    The  Third  Edition.     Now  ready.     One  Volume.     Price,  $3. 
We  have  spoken,  or  intended  to  speak,  heartily  in  praise  of  Dr.  Bond's  work.     It  has  un- 
mistakable evidence  of  thorough  medical  science  in  its  suV)ject  matter,  and  of  a  capital  author- 
ship in  its  style  and  treatment. — American  Medical  Journal. 

Piggofs  Dental  Chemistry  and  Metallurgy. 

Containing  Physiological    Chemistry,    as    applied    to    DenrLstry,    &c. 
By  A.  Snowden  Piggot,  M.D.,  Professor  of  Practical  -.xui  Analytical 
Chemistry,  &c.     In  One  Volume,  Octavo.     Price,  $3.00. 
We  think  the  work  is  one  which  should  be  in  the  hands  of  every  dentist.     Much  labor 

and  research  has  been  spent  on  it,  and  an  immense  amount  of  useful  information  combined 

»nd  given  in  a  very  desirable  form  to  the  profession. — Denial  Register. 


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